Lindengrove New Berlin
Inspection history, citations, penalties and survey trends for this long-term care facility in New Berlin, Wisconsin.
- Location
- 13755 W Fieldpointe Dr, New Berlin, Wisconsin 53151
- CMS Provider Number
- 525064
- Inspections on file
- 24
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lindengrove New Berlin during CMS and state inspections, most recent first.
Two residents with significant fall risk and cognitive impairment experienced multiple falls due to inadequate supervision and incomplete investigations. The facility did not consistently update care plans to address self-transferring behaviors or ensure that interventions were communicated to staff, resulting in repeated incidents and, in one case, a pelvic fracture.
A resident with significant neurological and physical impairments reported to their family that an aide intended to take a picture of their bowel movement. The family immediately notified the NHA by email, but the allegation was not reported to the state agency within the required timeframe because the NHA did not review the email until after a holiday. The facility lacked a process for monitoring and responding to time-sensitive allegations during weekends or holidays, resulting in delayed reporting.
A resident with multiple medical conditions developed a rash in skin folds, which was documented during a routine skin assessment. Despite facility policy requiring physician notification for changes in skin integrity, the physician was not informed, and staff could not provide a reason for this omission. Documentation showed the rash was treated with barrier cream, but no medical evaluation was sought.
A resident with cognitive impairment and physical disabilities suffered a head injury after slipping from a sit-to-stand lift during a transfer performed by only one CNA, despite the care plan requiring two staff. The CNA was unaware of the two-person requirement, and documentation regarding sling size and transfer procedures was lacking. The facility's investigation did not address whether proper procedures and equipment were used during the transfer.
A resident with significant cognitive and physical impairments was found with a large bruise and skin tears at the base of the neck, but the facility failed to thoroughly investigate the cause. Staff interviewed had not cared for the resident on the day of the injury, the injury was not properly measured or documented, and residents interviewed for safety concerns were from different units. The facility's report to authorities could not be verified, and the investigation did not follow established policy.
A resident with severe cognitive impairment and multiple medical conditions sustained a significant leg injury requiring surgery after hitting her shin on a sit-to-stand lift during a transfer. The facility failed to conduct a thorough investigation into the incident, and the resident was left alone on the toilet with the leg strap unfastened, contributing to the injury. The facility lacked a specific policy for the lift's use and did not provide adequate staff training, resulting in a deficiency in ensuring resident safety and supervision.
The facility was found to have deficiencies in the dishwashing process, potentially affecting all 87 residents. Dietary staff were observed handling dirty items and then clean items without proper hand hygiene or changing gloves, contrary to facility policy. The Kitchen Lead noted the staff were new and explained the sanitization process to them.
The facility failed to implement an effective infection prevention and control program, affecting residents, staff, and visitors. There was no documentation of investigations into infection outbreaks or a system to track staff illnesses. During a COVID-19 outbreak, the facility's line list was incomplete, and there was no investigation into the spread across units. Enhanced barrier precautions were not implemented for residents with wounds, and staff were unclear about the requirements. Additionally, the facility did not adequately track staff illnesses, contributing to ineffective infection management.
The facility failed to date opened insulin vials and pens, as observed in multiple medication carts and rooms. Insulin types such as Novolog, Lantus, and Lispro were found open and used without being dated, contrary to the facility's policy requiring the recording of the date opened and expiration. This deficiency was noted across various units and floors, highlighting a lapse in medication management protocols.
The facility failed to ensure safe and clinically appropriate self-administration of medications for three residents. One resident had medications at their bedside without an assessment or care plan, another self-administered medications left on their breakfast tray without proper documentation, and a third had unlabeled medications without physician orders or an assessment. These deficiencies highlight a lack of oversight and documentation in the facility's medication management process.
The facility failed to provide required written notifications of transfer, including appeal rights, to three residents transferred to the hospital due to changes in their conditions. The facility also did not notify the State Ombudsman as required. Interviews with staff revealed a lack of documentation and a systemic issue in the notification process.
The facility failed to provide written notice of the bed hold policy to three residents when they were transferred to the hospital. Despite the responsibility of floor nursing staff to issue these notices, they were not provided in these cases. One resident, with multiple medical conditions, was transferred due to severe symptoms, yet no bed hold notice was given. The facility's eInteract transfer form lacked the required regulatory information.
A facility failed to assess the necessity of a Foley catheter for a resident who was admitted without one and returned from hospitalization with it. The resident's medical records lacked documentation or a valid diagnosis justifying the catheter's use. Despite the absence of genitourinary issues in the hospital discharge summary, the facility did not evaluate the need for the catheter's removal, leading to a deficiency.
A resident with multiple diagnoses, including Alzheimer's and dementia, was unable to be transferred due to a shortage of appropriate slings for a Hoyer lift. Staff reported a longstanding issue with sling availability, requiring them to search different units or the laundry. Despite management's belief that slings were accessible, surveyors found none on linen carts, and staff confirmed the ongoing problem, affecting the accommodation of resident needs.
A resident admitted with surgical incision wounds did not receive appropriate care and monitoring in accordance with professional standards. The facility failed to document the incisions in the care plan, and no comprehensive assessments or orders were in place. Staff interviews revealed a lack of awareness and documentation regarding the resident's surgical wounds, leading to inadequate care during the resident's stay.
A resident with multiple health issues experienced two falls in one day due to inadequate supervision and failure to implement a fall mat as per the care plan. The facility's investigation lacked thoroughness, with missing staff statements and inconsistent documentation, contributing to repeated falls and injuries.
A resident admitted with a Foley catheter did not receive timely orders for catheter care and monitoring, as required by facility policy. Despite having multiple diagnoses, including a urinary tract infection, the necessary orders were delayed, and the facility did not provide a reason for this oversight. The unit manager and DON acknowledged that standing orders should have been implemented upon admission.
Failure to Prevent Accidents Due to Inadequate Supervision and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, as required by policy. Both residents had a history of falls and were identified as being at risk, yet the facility did not conduct thorough investigations following multiple fall incidents. For one resident, repeated self-transferring behaviors were documented, but these were not addressed in the care plan, and interventions were not updated to reflect the ongoing risk. The facility's investigations into the falls did not consistently include key information such as who last observed the resident, what the resident was doing prior to the fall, when the resident was last toileted, or whether prior interventions were in place and effective at the time of the incident. In several instances, the facility's documentation and investigative process were incomplete. Staff statements were not always obtained or included in the investigation packets, and there was a lack of evidence that staff were interviewed regarding the circumstances of the falls. The care plans for the residents did not address self-transferring behaviors, despite staff being aware of these actions. Additionally, interventions such as offering toileting with every interaction were not consistently communicated to or implemented by direct care staff, as observed by the surveyor during interviews and record reviews. The residents involved had significant medical histories, including cognitive impairment, hemiplegia, diabetes, and chronic kidney disease, which increased their vulnerability to falls and injuries. Despite these risk factors, the facility did not ensure that all fall prevention interventions were in place or that staff were adequately informed of changes to care plans. The lack of thorough investigation and failure to address known risk behaviors contributed to repeated falls and, in one case, a pelvic fracture requiring hospitalization.
Failure to Timely Report Allegation of Mistreatment Due to Inadequate Weekend/Holiday Procedures
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure the timely reporting of suspected abuse, neglect, or mistreatment in accordance with federal and state requirements. Specifically, an allegation of mistreatment and neglect was reported by a resident's daughter via email to the Nursing Home Administrator (NHA) on a Sunday evening. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours if not. However, the incident was not reported to the State Survey Agency until two days later, after the holiday weekend. The resident involved had significant medical conditions, including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage, polyneuropathy, morbid obesity, and chronic pain syndrome. The resident was cognitively intact, able to communicate effectively, and had no documented behavioral or depressive symptoms. The concern arose when the resident informed their daughter that an aide had stated an intention to take a picture of the resident's bowel movement, prompting the daughter to immediately notify the NHA via email. Despite the facility's established policy, the NHA did not review the email until after the holiday, resulting in a delay in reporting the allegation to the state agency. The NHA confirmed that there was no process in place for monitoring time-sensitive emails over weekends or holidays, and no other staff were assigned to scan for such communications. The delay in reporting was attributed to the NHA being the sole recipient and reviewer of these communications, and the lack of an alternative process for timely response during periods when the NHA was unavailable.
Failure to Notify Physician of Resident's Rash
Penalty
Summary
A deficiency occurred when a resident with significant medical conditions, including hemiplegia, polyneuropathy, morbid obesity, and chronic pain syndrome, developed a rash in the abdominal and breast folds. The facility's policy required that any changes in skin integrity be reported to the physician, and the resident's care plan included interventions to minimize skin breakdown, such as regular skin assessments and staff assistance with hygiene and repositioning. Despite these protocols, a skin assessment documented the presence of a rash, but there was no evidence that the physician was notified as required. The Skin Only Evaluation completed on the resident indicated a rash with moderate redness, but the section for provider notification was left blank, and no education was documented as provided. A late entry nurse's note, created several weeks after the initial finding, stated that the resident was cleaned and barrier cream was applied, but again, there was no indication that the physician was informed. Interviews with facility staff, including the Nurse Supervisor and DON, confirmed that the physician was not contacted regarding the rash, and staff were unable to provide a reason for this omission. The deficiency was further substantiated by the facility's own documentation and staff statements, which showed a lack of adherence to both the facility's skin care policy and professional standards of practice. The failure to notify the physician of the resident's rash meant that appropriate medical evaluation and treatment could not be initiated in a timely manner, as required by the resident's care plan and facility protocols.
Failure to Follow Care Plan and Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, dementia, paraplegia, and other significant medical conditions experienced a fall while being transferred using a sit-to-stand lift. The resident's care plan and CNA Kardex both specified that transfers required the use of a sit-to-stand lift with assistance from two staff members. However, on the evening of the incident, only one CNA was present during the transfer. The resident slipped out of the sling, fell, struck the back of her head, and briefly lost consciousness, resulting in a laceration that required two staples. The investigation revealed that the CNA performing the transfer was not aware that two staff were required for the procedure, despite this being documented in the care plan and Kardex. The CNA also did not recall if the transfer required one or two staff or what sling size was needed. Interviews with other staff indicated that sling sizes were not documented on the Kardex or care plan, and slings were not labeled for individual residents. There was also no evidence of recent training for staff on determining sling size, proper sling attachment, or safe transfer procedures prior to the incident. The facility's investigation into the incident did not address whether the correct sling size was used, if the sling was properly attached, or if the CNA had adequate knowledge of the transfer requirements. The root cause analysis focused on the resident's underlying diagnoses and loss of balance, but did not fully explore staff compliance with the care plan or equipment use. The surveyor noted that the care plan was not followed, as only one staff member assisted with the transfer, directly contributing to the resident's fall and injury.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse or neglect involving a resident who was found with a large bruise and skin tears at the base of the neck. The facility's investigation did not include interviews with staff members who had direct contact with the resident on the day the injury was discovered. Instead, statements were obtained from staff who were not assigned to the resident on that day and had no knowledge of the incident. Additionally, the investigation did not include a physical assessment or recreation of the transfer process to determine if the injury could have been caused by the mechanical lift, as was suggested by facility administration. The documentation of the injury was inconsistent, with conflicting dates reported for when the injury was discovered and discrepancies in the number of open areas within the bruise. The bruise itself was not measured or thoroughly described in the medical records. Furthermore, the residents interviewed to assess safety concerns were from different units and floors, and therefore did not interact with the same staff as the injured resident, limiting the effectiveness of the investigation in ruling out potential abuse by staff members involved in the resident's care. The resident involved had significant medical needs, including hemiplegia, moderate cognitive impairment, and was dependent on staff for all activities of daily living, requiring the use of a full mechanical lift for transfers. The facility's investigation summary included a statement that the police were notified, but verification with the police department revealed that no such report was filed. The investigation did not follow the facility's own policy for a comprehensive and prompt investigation of injuries of unknown origin, as required.
Inadequate Supervision and Investigation of Resident Injury
Penalty
Summary
The facility failed to ensure that a resident, identified as R12, remained free from accident hazards and received adequate supervision and assistance devices to prevent accidents. R12, who has severe cognitive impairment and multiple medical conditions including Chronic Kidney Disease and Vascular Dementia, sustained a significant leg injury requiring surgical intervention. The injury occurred when R12 hit her left shin on a sit-to-stand lift during a transfer, leading to a hematoma that later ruptured. The facility did not conduct a thorough investigation to determine how the injury occurred, and the CNA's account of the incident lacked details on how R12's leg was injured. R12's care plan indicated that she was dependent on assistance for mobility and toileting, and she was at risk for falls. Despite this, R12 was left alone on the toilet with the leg strap of the sit-to-stand lift unfastened, which allowed her to move her leg and sustain the injury. The facility's investigation into the incident was inadequate, as it did not explore whether the transfer was completed correctly or how R12's leg came into contact with the lift. Additionally, there was no documentation of interventions to prevent further incidents, and R12 was not observed wearing protective tubi grips as indicated in her care plan. The facility lacked a specific policy and procedure for the use of the sit-to-stand lift, and there was no evidence of education or training provided to staff regarding its safe use. The CNA involved in the incident reported that R12 was left alone on the toilet, and the leg strap was removed, which contributed to the injury. The facility's failure to conduct a thorough investigation and implement appropriate interventions to prevent future incidents highlights a deficiency in ensuring resident safety and adequate supervision.
Deficiency in Dishwashing Sanitation Process
Penalty
Summary
The facility was found to have deficiencies in the dishwashing process, which could potentially affect all 87 residents. During an observation, dietary staff were seen handling dirty items and placing them into the dishwashing machine, then handling clean items without performing hand hygiene or changing their contaminated gloves. This was contrary to the facility's policy, which requires that all flatware, serving dishes, and cookware be washed, rinsed, and sanitized after each use, and that dish machines be checked prior to meals to ensure proper functioning and appropriate temperatures for cleaning and sanitization. The surveyor observed that the dietary staff did not allow the dishes to air dry and used the same contaminated gloves from loading the dirty used trays to remove the trays once cleaned. The staff member, DS-V, was observed not performing hand hygiene and not changing contaminated gloves between handling used items and then clean items. When questioned, DS-V stated they were not actually touching the items but just the rack. The Kitchen Lead, KL-X, explained the sanitization process to the staff, noting that they were fairly new employees. The concerns were shared with the Nursing Home Administrator and Director of Nurses during the facility exit meeting.
Inadequate Infection Control and Tracking in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, which had the potential to affect all 87 residents, staff, and visitors. The facility did not have documentation of investigations into infection outbreaks, nor did it have a system to track all facility staff illnesses. During a recent COVID-19 outbreak, the facility's line list was incomplete and did not include all staff or document control measures to limit the spread of the virus. Additionally, there was no investigation into how COVID-19 spread across different units, and the facility lacked a specific policy for COVID-19 outbreaks. The facility also failed to implement enhanced barrier precautions for residents with wounds, as required by their infection control policy. During wound care observations, staff did not use enhanced barrier precautions, such as donning gowns, for residents with open wounds. There was no signage or supplies for enhanced barrier precautions outside the rooms of residents with wounds, and the facility's staff were unclear about the requirements for implementing these precautions. Furthermore, the facility did not adequately track staff illnesses, which is crucial for preventing the spread of infections. The facility's system for tracking staff call-ins was incomplete, and there was no trending or tracking information related to staff symptoms, unit worked, or job position. The facility's infection preventionist and director of nursing were responsible for tracking staff illnesses, but they did not have comprehensive information from all departments. This lack of tracking and documentation contributed to the facility's inability to effectively manage and control infection outbreaks.
Failure to Date Opened Insulin Vials
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the dating of insulin vials and pens when opened. During the survey, it was observed that multiple insulin vials and pens across different medication carts and rooms were open and used but not dated when opened. This included Novolog, Lantus, Insulin 70/30, Lispro, and Humulin R vials, some of which were not labeled with a name. The facility's policy requires that the date opened and the shortened expiration date be recorded on multidose vials, which was not adhered to in these instances. The surveyor's observations were made on various floors and units, including the 2nd floor left hall medication cart, 1st floor unit B and A medication carts, and medication rooms on the 2nd floor Cottage Unit and 1st floor [NAME] Court. The facility policy, dated May 2018, specifies that vials and ampules of injectable medications should be used in accordance with the manufacturer's recommendations or the provider pharmacy's directions, and that the date opened must be recorded. Despite this policy, the surveyor found several instances where insulin vials were not dated, indicating a lapse in adherence to the facility's medication management protocols.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that it was safe and clinically appropriate for residents to self-administer medications, as observed in three cases. Resident R63 was found with medications at their bedside without an assessment, physician's order, or care plan for self-administration. Despite having a mental status score indicating no cognitive impairment, there was no documentation supporting the safety and appropriateness of self-administration for R63. Resident R75 was observed with medication cups left on their breakfast tray, which they self-administered without a formal assessment or care plan in place. The resident reported that staff routinely left medications for them to take with breakfast, but there were no orders or assessments to support this practice. This lack of documentation and oversight indicates a failure to ensure the resident's ability to safely self-administer medications. Resident R56 was found with several bottles of medication at their bedside, none of which had pharmacy labels or physician orders. The resident's medical record lacked an assessment to determine their ability to self-administer medications safely, and there was no individualized care plan. Although a self-administration assessment was eventually completed, it was not in place at the time of the surveyor's observation, highlighting a deficiency in the facility's process for managing self-administration of medications.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification of transfer, including appeal rights, to three residents who were transferred to the hospital due to changes in their conditions. Specifically, the facility did not provide written notification to the residents or their representatives, nor did they notify the State Ombudsman as required. This deficiency was identified for three residents: one who was transferred on October 12, 2024, another on December 31, 2024, and a third on June 13, 2024. In each case, the facility lacked documentation of the required notifications. Interviews with the Nursing Home Administrator and Director of Nursing revealed that floor nursing staff were responsible for providing the written notifications, while the facility's Social Worker was tasked with notifying the ombudsman in certain situations. However, the facility was unable to produce the necessary documentation for the transfers of the three residents. The surveyor's review of the medical records and interviews with staff confirmed the absence of the required notifications, highlighting a systemic issue in the facility's process for handling hospital transfers.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to three residents (R62, R283, and R67) when they were transferred to the hospital. R62 was transferred on 10/12/24 due to a change in condition, but the facility did not have a written notice of the bed hold policy for this transfer. Similarly, R283 was transferred on 12/31/24, and the facility again failed to provide the required written notice. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that floor nursing staff were responsible for providing the notice, but it was not done in these cases. R67, who had multiple medical conditions including chronic congestive heart failure and type 2 diabetes mellitus, was transferred to the hospital on 6/13/24 after experiencing severe symptoms. Despite the severity of the situation, there was no evidence that a bed hold notice was provided to R67 or his representative. The facility provided an eInteract transfer form, but it lacked the necessary regulatory information regarding the bed hold policy. The NHA was informed of these deficiencies, but no additional information was provided to address the issue.
Failure to Assess Catheter Necessity for Resident
Penalty
Summary
The facility failed to ensure that a resident who was admitted without an indwelling catheter and later returned from hospitalization with a Foley catheter was assessed for the necessity of the catheter. The resident, who had diagnoses including hypertensive chronic kidney disease, anemia, and vascular dementia, was observed with a catheter upon return to the facility. The hospital discharge summary did not document any genitourinary problems or provide a clinical indication for the catheter's use. Despite this, the facility did not assess the resident for catheter removal or obtain valid medical justification for its continued use. The resident's medical records and interviews with the resident's son revealed that the catheter was not present before hospitalization and was not justified by any documented medical condition upon return. A hospice progress note later indicated the catheter was necessary for end-of-life care, but this was not supported by a valid diagnosis. The facility's failure to assess the necessity of the catheter and the lack of documentation for its use led to the deficiency identified by the surveyor.
Deficiency in Sling Availability for Resident Transfers
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, received reasonable accommodation of needs due to the unavailability of appropriate slings for a Hoyer mechanical lift. R1, who was admitted with diagnoses including fractures, Alzheimer's disease, dementia, and seizure disorder, was dependent on staff for transfers. During the survey, it was observed that slings were not readily available, and staff had to search different units or the laundry to find the correct size. This issue potentially affected 24 out of 87 residents who required similar transfers. Interviews with staff revealed that there was a longstanding shortage of slings, and staff often had to 'eyeball' residents to choose a sling based on convenience rather than a proper guide. Although a chart indicating sling sizes was put up, it lacked a weight guide, and slings were not consistently available on linen carts as expected. The Occupational Therapist reported an incident where R1 could not be transferred due to the unavailability of a sling, and the Unit Manager was informed but did not recall any concerns about sling availability. The Nursing Home Administrator and Director of Nursing were unaware of the shortage and stated that slings should be available on linen carts or in resident rooms. However, during the survey, no slings were found on the carts, and staff confirmed the ongoing issue. The deficiency was highlighted by the surveyor, who noted that slings were necessary for weighing residents upon admission, indicating a need for them to be consistently available regardless of immediate necessity for transfers.
Failure to Provide Proper Care for Surgical Incisions
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice for surgical incision wounds. The resident, who was admitted with surgical incision wounds, did not have comprehensive assessments or orders in place for the care of these incisions. The resident's skin integrity care plan did not reflect the presence of surgical wounds, and there was no documentation of the surgical incisions in the resident's medical records. Upon admission, the nursing staff documented the resident's skin as intact, failing to note the three surgical incisions. The facility's medication and treatment administration records did not include orders for monitoring the surgical incisions until the day the resident was discharged. Interviews with staff revealed a lack of awareness and documentation regarding the resident's surgical wounds, and the necessary assessments and care plans were not implemented. The surveyor's findings highlighted that the facility's staff, including the wound nurse and unit manager, did not conduct the required assessments or establish care plans for the resident's surgical incisions. The nursing home administrator and director of nursing acknowledged the oversight and the absence of appropriate care and monitoring for the resident's surgical wounds during their stay at the facility.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and the implementation of assistance devices to prevent accidents for a resident who was reviewed for falls. The resident, who had multiple diagnoses including encephalopathy, diabetes, and visual loss, experienced two falls on the same day. The first fall occurred in the morning when the resident was found sitting on the bathroom floor, confused and with no visible injuries. Despite the resident's care plan indicating the need for a fall mat, it was not in place at the time of the fall. The facility's fall investigation did not include a root cause analysis or statements from staff who might have witnessed the incident, leaving gaps in understanding how the fall occurred. Later that day, the resident experienced a second fall, resulting in facial lacerations and a hospital visit. Again, the fall mat was not in place as per the care plan, and the facility's documentation was inconsistent regarding the circumstances of the fall. The CNA who found the resident did not provide details about the room's setup or the resident's activities prior to the fall. Interviews with staff revealed confusion and lack of clarity about the events leading to the fall, and the facility's investigation did not adequately address these issues. The facility's failure to conduct thorough investigations and implement necessary interventions, such as the fall mat, contributed to the resident's repeated falls and injuries. The lack of detailed documentation and staff statements further hindered the facility's ability to prevent future incidents. The report highlights the need for comprehensive fall prevention measures and thorough investigations to ensure resident safety.
Failure to Provide Timely Catheter Care Orders
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services related to catheter care. The resident was admitted with a Foley catheter but did not have orders in place for catheter care and monitoring until several days after admission. The facility's policy requires that nursing staff assess catheter use and obtain physician orders upon admission, but this was not done in a timely manner for the resident. The resident had multiple diagnoses, including fractures, muscle weakness, cognitive communicative deficit, Alzheimer's disease, dementia, and a urinary tract infection with urinary retention. Despite these conditions, the necessary orders for catheter care and monitoring were delayed, and the facility did not provide a reason for this oversight. The unit manager and director of nursing acknowledged that standing orders should have been implemented upon admission, but this did not occur, leading to the deficiency.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
