Lindengrove Waukesha
Inspection history, citations, penalties and survey trends for this long-term care facility in Waukesha, Wisconsin.
- Location
- 425 N University Dr, Waukesha, Wisconsin 53188
- CMS Provider Number
- 525422
- Inspections on file
- 20
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Lindengrove Waukesha during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required written bed-hold information and to notify the State LTC Ombudsman for multiple facility-initiated discharges to the hospital. In three separate unplanned transfers, residents were sent to an acute hospital and did not return, yet there was no documentation that the bed-hold policy, daily cost, or appeal rights were explained, and no completed bed-hold forms were found in the EMR. The SSD and nursing leadership confirmed that bed-hold documentation was missing, and the Ombudsman reported not receiving the facility’s discharge notifications, despite facility policy requiring that residents or their representatives receive written bed-hold information at transfer and that all facility-initiated discharges, including hospitalizations, be reported to the Ombudsman.
Two residents experienced failures in timely and complete reporting of alleged abuse and misappropriation. In one case, a resident's missing wallet was initially reported and investigated, but the required 5-day follow-up report was not submitted to the State Agency. In another case, a resident reported being yelled at and scared by a CNA, but the incident was not reported or documented as required, and management was unaware until informed by a surveyor. Both incidents reflect noncompliance with the facility's policy for reporting abuse and misappropriation.
A resident with diabetes and a recent hospital stay did not receive prednisone according to the prescribed tapering schedule due to transcription errors in the EMR, resulting in missed and incorrect doses. Additionally, staff failed to notify the provider of two blood glucose readings over 400 mg/dL, with no documentation of provider notification or additional interventions, despite facility policy requiring such actions.
Two residents with newly identified or existing pressure injuries did not receive timely wound treatment orders. In both cases, wounds were identified and noted in documentation, but treatment orders were either not entered into the EMR or were delayed for an extended period. Facility policy required prompt assessment and provider notification, but these steps were not consistently followed, resulting in a lack of timely wound care.
Two residents with chronic respiratory conditions did not receive their prescribed inhalers as ordered due to medication unavailability. Staff documented missed doses and contacted the pharmacy, but there were delays in obtaining necessary management authorization for high-cost medications and breakdowns in communication, resulting in multiple missed doses despite pharmacy attempts to supply the medications.
A resident at high risk for pressure injuries developed new wounds due to the facility's failure to implement necessary interventions, such as an air mattress and repositioning. The care plan was not updated with recommended interventions, and weekly skin assessments were not completed. Observations showed non-compliance with orders for offloading and repositioning, leading to the deterioration of the resident's condition.
The facility failed to maintain proper sanitation and food handling practices, with soiled garbage cans, undated and uncovered food items, and improperly stored scoops in the kitchen. Additionally, a dirty mop and bucket were found near a food service cart in a serving area, and sinks were observed to be very dirty. These issues were noted to potentially affect 44 residents.
The facility did not provide adequate telephone access for residents on the second floor, affecting their privacy during calls. While first-floor residents had phones in their rooms, those on the second floor had limited access, with only two cordless phones available, one of which was inoperable. A nurse often used her personal phone to facilitate private calls for residents, as the facility's landline was located in the nurse's station, which did not allow for privacy.
A resident was observed self-administering medications without a proper assessment or physician's order, contrary to facility policy. The resident's medical record lacked documentation of an assessment or care plan for self-administration, and an LPN marked the medications as administered on the MAR. The facility acknowledged the oversight and conducted the necessary assessment and review the following day.
A resident with severe cognitive impairment fell and was hospitalized with a hip fracture and brain bleed. The facility failed to notify the resident's representative and attending physician of the incident, as confirmed by the surveyor's review and the Interim DON. The agency nurse involved could not recall making the necessary notifications.
A resident with severe cognitive impairment was prescribed Trazodone and Mirtazapine without obtaining informed consent from their POA, as required by the facility's policy. The oversight was acknowledged by the DON during a survey, highlighting a failure to comply with the protocol for informed consent for psychoactive medications.
A resident reported two shirts missing after being laundered by the facility. Despite notifying staff and discussing the issue in a resident council meeting, the facility did not follow up adequately. Interviews revealed unclear protocols for handling missing items, and no grievance was filed. The facility lacked a policy on missing items, leading to unresolved issues.
A resident admitted with chronic conditions did not receive a baseline care plan review or a copy within 48 hours, as required by facility policy. Despite being cognitively intact, the resident was not involved in the care planning process, and the signed care plan was missing from the medical record. Interviews with nursing directors confirmed the policy was not followed.
A resident at risk for pressure injuries did not have a comprehensive care plan in place, despite being identified as at risk through assessments. The resident was observed using preventive measures like a pressure reduction mattress, but the facility's policy requiring a documented care plan was not followed. The deficiency was acknowledged by the DON, but no corrective actions were provided during the survey.
Two residents in an LTC facility, both with severe cognitive impairments and dependent on staff for ADLs, were found with long, dirty fingernails. One resident was observed scratching open wounds, while the other had contracted fingers with nails touching the palms. Despite facility policy requiring nail care on bath days, there was no documentation or consistent performance of this care. Staff were unsure about the inclusion of nail care in care plans, and the deficiency was reported to the interim DON and NHA.
The facility failed to provide meaningful weekend activities for two residents, who expressed a desire for organized group activities. Instead, the facility offered activity packets and TV options, which did not meet the residents' needs. Additionally, the facility did not complete a required section of the MDS for one resident, documenting their activity preferences.
A resident admitted to a facility after a fall with head trauma was assessed as high risk for falls, but a falls care plan was not initiated until nearly two months later. The resident experienced multiple falls during this period, and the care plan was not updated following these incidents. Despite reminders to use the call light, the resident continued to self-transfer, leading to further falls. Staff interviews indicated the resident preferred independence but was compliant with call light use in recent months. The facility's failure to implement timely and effective fall prevention measures demonstrated a deficiency in care.
A resident with an indwelling catheter lacked a valid medical justification, monitoring, and care plan, leading to deficiencies in catheter care and dignity. The resident, with multiple diagnoses and on hospice care, had no documented orders or interventions for catheter management. Observations showed the catheter bag was not in a privacy bag, and staff were unsure about care procedures, highlighting a failure to follow facility policy.
A resident with chronic respiratory issues and on hospice care was found to have unlabeled oxygen tubing and no protective coverings as per facility protocol. There was no care plan for oxygen use, and staff were unclear about procedures for replacing and labeling oxygen equipment, leading to inconsistent care.
The facility failed to ensure accurate medication administration for two residents. A resident did not receive Hydrochlorothiazide as it was not found in the cart, yet it was signed as given. Another resident did not receive Voltaren gel because it was used up and not reordered, but it was also signed as administered. Both medications were available in the Omnicell system, indicating a failure in following procedures.
Two residents in a LTC facility were not adequately monitored for the effectiveness and side effects of their psychotropic medications. One resident was prescribed Duloxetine for depression without a care plan or monitoring, despite having no depressive symptoms. Another resident was on Trazodone and Mirtazapine without behavior monitoring to assess medication effectiveness. Staff were unaware of specific monitoring requirements, and the facility's psychoactive medication protocol was not followed, leading to deficiencies in medication management.
The facility experienced a medication error rate of 11.11%, exceeding the acceptable 5% threshold. Three residents were affected: one did not receive Voltaren Gel, another missed a dose of Hydrochlorothiazide, and a third did not receive Amlodipine, despite all being signed out as administered. Medications were available in the Omnicell system but were not given, and documentation errors were noted.
A resident received double the prescribed dose of Vancomycin due to a transcription error, resulting in 16 extra doses being administered over a period. The error was identified by a surveyor, and no negative effects were found in the resident's medical record.
The facility failed to properly store and label medications, with deficiencies noted in 3 out of 5 medication carts/storage rooms. Temperature logs were missing or incomplete in medication storage rooms, and insulin glargine was stored beyond its use-by date. The Interim DON confirmed the lack of temperature monitoring, and the surveyor noted the expired insulin was still in use despite guidelines.
The facility did not post daily nurse staffing data, including the date, resident census, and total hours worked by RNs, LPNs, and CNAs. A surveyor found outdated postings, and interviews revealed confusion about who was responsible for updates on weekends or when the scheduler was absent. This affected all 44 residents.
A facility failed to properly assess and monitor a resident, resulting in the development of a stage 3 pressure injury. Despite being at risk, the resident's care plans lacked preventive interventions, and required skin checks were not documented. Staff interviews revealed a lack of awareness of the injury, and the facility could not provide additional information on its development.
A facility failed to accurately document a resident's code status in the EMR, showing the resident as a Full Code despite having a DNR order. This discrepancy was discovered when the resident was found nonresponsive, and the family had to sign another DNR form.
A resident with Alzheimer's Disease and severe cognitive impairment experienced an unwitnessed fall, which was not documented or investigated by the facility. Despite multiple attempts to contact the nurse on duty, no additional information was obtained, violating the facility's policy for fall incident review.
A resident with moderate cognitive impairment and frequent incontinence was left in wet clothing for an extended period, from at least 12:40 PM to 2:10 PM, without being checked or changed. The CNA responsible admitted to not checking the resident since 10:00-10:30 AM, citing understaffing. This neglect was confirmed by the ADON, who acknowledged that residents should be checked every two hours.
A CNA failed to change gloves during incontinence care for a resident with right hemiplegia, Alzheimer's disease, and dementia. The CNA used the same gloves to clean the resident's perineal area, apply a clean brief, and change the resident's oxygen tubing, violating the facility's hand hygiene policy.
Failure to Provide Bed-Hold Notices and Notify Ombudsman of Facility-Initiated Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notification of its bed-hold policy to residents and/or their representatives prior to transfer to the hospital, and failure to notify the State Long-Term Care Ombudsman of facility-initiated discharges. For one resident (R1), who had moderately impaired cognition with a BIMS score of 11/15, the EMR showed an unplanned transfer to an acute hospital after staff noted a cut, bruise, and bleeding on the right eyelid and sent the resident for evaluation. Progress notes documented that the POA was notified of the transfer and later contacted about whether the bed should be held, with the POA declining. However, there was no documentation that the bed-hold process, including cost per day and appeal rights, was explained, no completed bed-hold form, and no documentation that the Ombudsman was notified of the facility-initiated discharge. For a second resident (R9), who had no cognitive impairment with a BIMS score of 15/15, the admission and discharge-return-anticipated MDS assessments showed an unplanned discharge to an acute hospital from which the resident did not return. Review of the EMR revealed no documentation that a bed hold was discussed with the resident or representative at the time of transfer, no record of the daily cost of services, and no indication of whether a bed hold was chosen. There was also no documentation that the Ombudsman was notified of this facility-initiated discharge to the hospital. During interview, the Social Services Director confirmed that a bed-hold form was not completed for this resident. For a third resident (R10), the records showed an unplanned discharge to the hospital for abnormal vital signs, with no return to the facility. EMR review again showed no documentation that a bed hold was discussed with the resident or representative, no record of the cost per day, and no indication of a decision regarding bed hold. There was also no documentation that the Ombudsman was notified of this discharge. The Social Services Director described a practice of faxing a monthly admissions/discharge report to the Ombudsman and then discarding the fax documentation, and the Ombudsman’s office reported not having received the facility’s monthly discharge lists since a specified prior date and stated the facility was told to maintain documentation of these notifications. Facility policies required that residents/representatives be informed and receive a copy of the bed-hold procedure upon transfer, that responses be documented, and that the appropriate Ombudsman be notified of all facility-initiated discharges, including hospitalizations, but these requirements were not met for the three reviewed residents.
Failure to Timely Report Alleged Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely and complete reporting of alleged abuse and misappropriation involving two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent fall with fracture, was reported by their Activated Power of Attorney (APOA) to have a missing wallet. The Director of Nursing (DON) was notified, and an initial report was submitted to the State Agency on the same day. The facility initiated an investigation and contacted local law enforcement. However, the required 5-day follow-up report to the State Agency was not submitted. The Nursing Home Administrator (NHA) acknowledged the omission, citing issues with email account changes and inability to locate confirmation of the 5-day report submission. In the second case, a cognitively intact resident reported to a surveyor that a Certified Nursing Assistant (CNA) had yelled at and scared them several weeks prior. The resident had informed another CNA, who stated they would file a complaint but did not do so, nor did they inform facility management. The incident was not documented in the facility's incident or grievance logs for the relevant period. When interviewed, the CNA who received the complaint did not consider the situation abusive and did not escalate the report. Facility management, including the Assistant Director of Nursing (ADON) and Social Worker (SW), were unaware of the incident until informed by the surveyor. A grievance was only filed after the surveyor's inquiry, and the alleged perpetrator was no longer employed at the facility. The facility's own policy requires immediate or timely reporting of all allegations of abuse, neglect, or misappropriation to the State Agency and other authorities, as well as submission of a follow-up investigation report within five working days. In both cases, the facility failed to adhere to these requirements: the 5-day follow-up report was not submitted for the missing wallet, and the verbal abuse allegation was not reported to the State Agency at all. These failures were confirmed through interviews and record reviews conducted by the surveyor.
Failure to Accurately Transcribe Medication Orders and Notify Provider of Elevated Blood Glucose
Penalty
Summary
The facility failed to accurately transcribe and administer a prednisone taper as ordered for a resident who was readmitted following a hospital stay. The hospital discharge summary specified a tapering schedule for prednisone, but the orders entered into the electronic medical record (EMR) did not match the hospital's instructions. The medication administration record (MAR) showed inconsistencies in the dosage and administration dates, with some doses marked as refused and others not aligning with the prescribed taper. The resident reported receiving incorrect doses and missing doses on certain days. Additionally, the facility did not notify the provider of elevated blood glucose levels for the same resident, who had a diagnosis of diabetes mellitus. The resident's care plan included blood sugar monitoring as ordered by the physician, but the initial orders lacked specific parameters for when to notify the provider. Blood glucose readings over 400 mg/dL were recorded on two occasions, but there was no documentation that the provider was notified or that additional insulin or rechecks were performed. Staff interviews revealed uncertainty about notification protocols in the absence of explicit parameters, and the Director of Nursing confirmed that there was no evidence of provider notification for the elevated readings. The resident was cognitively intact and able to report her experiences, stating that staff did not respond to her high blood glucose readings and that she did not receive the correct prednisone taper. The facility's policies required medications to be administered as prescribed and for providers to be updated as needed, but these protocols were not followed in this case, resulting in the deficiencies identified.
Failure to Obtain Timely Wound Treatment Orders for Pressure Injuries
Penalty
Summary
The facility failed to obtain timely wound treatment orders when pressure injuries were identified for two residents. For one resident admitted with surgical aftercare and muscle weakness, a new mixed stage 1-2 pressure injury was identified during care, and although the medical doctor was notified and orders were reportedly received, no treatment orders were entered into the electronic medical record (EMR) during the resident's stay. The care plan did not address the pressure injury until several days later, and the wound was not entered into the facility's risk management system. Interviews with nursing staff and administration confirmed that the expected process of documenting the wound, obtaining and entering orders, and updating the care plan was not followed. Another resident, admitted with diabetes and vascular dementia, had a stage three pressure injury to the coccyx upon admission. Documentation showed that no treatment order for this wound was entered until two weeks after admission, despite the presence of the wound being noted in nursing assessments. The only order present on admission was for a moisture barrier cream, which was not signed off as administered. The facility's wound nurse confirmed that there was no wound nurse or system in place prior to her tenure, and that treatment orders were not obtained in a timely manner for this resident's pressure injury. Facility policy required collaboration with the interdisciplinary team, prompt skin assessments, provider notification, and timely updates to care plans and treatment orders for any abnormal skin findings. However, in both cases, the process for obtaining and documenting wound care orders was not followed, resulting in a lack of timely treatment for identified pressure injuries.
Failure to Provide Ordered Respiratory Medications Due to Availability Issues
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered as ordered for two residents with chronic respiratory conditions. For one resident with chronic respiratory failure and hypoxia, there was an order for a Breztri inhaler to be given twice daily. Documentation showed that multiple doses were not administered because the medication was unavailable, with staff indicating that the pharmacy required management authorization due to the high cost. Despite pharmacy requests for authorization, the necessary approval was not completed, and the medication was not received or administered as ordered. Nursing staff documented the unavailability and contacted the pharmacy, but there was a lack of follow-up communication with management to resolve the issue, and the Director of Nursing was not aware that authorization was needed. Another resident with COPD and asthma had an order for an Advair inhaler to be administered twice daily. The medication administration records indicated several missed doses due to the inhaler being unavailable, with notes stating the pharmacy was contacted and the medication was on order. The resident reported not receiving the inhaler consistently during their stay. The pharmacy confirmed that the inhaler had been sent and should have been available for all scheduled doses, but documentation verified that not all doses were administered. The facility's policy required that if a regularly scheduled medication was not available, staff should document the reason, notify the physician if a certain number of doses were missed, and follow procedures for obtaining the medication. In both cases, there was a breakdown in communication and follow-through, resulting in residents not receiving their prescribed respiratory medications as ordered.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and promote healing for a resident identified as high risk for pressure injuries. The resident was admitted with pressure injuries on the left heel and right lateral foot, which resolved, but later developed new pressure injuries on the right lower extremity and buttocks. Despite a physician's order for an air mattress, it was never implemented, and the care plan for actual skin impairment was not initiated in a timely manner. Weekly skin assessments were not completed as per facility policy, and the care plan was not revised with interventions to promote healing. Surveyors observed that orders for repositioning and heel offloading were not implemented, and the resident was seen removing dressings and scratching open areas with dirty fingernails. The resident's care plan and CNA Kardex were not updated with new interventions recommended by the wound care doctor, such as offloading, repositioning, and pillow boots. The facility's failure to assess and update the resident's pressure injury care plan, monitor dressings, and provide repositioning led to the development and deterioration of pressure injuries, creating a finding of immediate jeopardy. The facility's policy on pressure injury prevention and managing skin integrity was not followed, as evidenced by the lack of comprehensive assessments and documentation of the resident's pressure injuries. The resident's air mattress was not upgraded as ordered, and there were no changes to the care plan or CNA Kardex to include interventions discussed in the wound care doctor's progress notes. The facility's failure to implement changes and revisions to the care plan and CNA Kardex, complete skin assessments, and ensure interventions were in place contributed to the deficiency.
Removal Plan
- All nurses and CNAs have been educated on the facility's skin prevention policy.
- All nurses and CNAs have been educated on the notification process of skin changes. Detailing that changes be communicated to resident provider and clinical leadership who then coordinates with wound NP, dietician, and provider as needed.
- Facility skin sweep completed.
- Facility residents care plans reviewed for at risk skin and updated as needed.
- Facility residents with skin alterations have had a review of their care plan, RN comprehensive skin evaluations, interventions, and treatment plans in place.
- Daily the DON or designee will review progress notes, risk assessments and 24-hour boards for any resident alteration of skin integrity.
- Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to provide the education.
- Staff education will occur prior to the next shift and new agency staff will be educated upon their first shift.
- Pressure Injury Prevention and Managing Skin Integrity policy reviewed and reviewed with Medical Director.
- Interdisciplinary Team to have weekly wound meetings to review status to include: pressure injury Policy and Procedure compliance. All findings will be reported to QAPI committee.
- DON or designee will audit 5 medical records to ensure the skin policy and procedure are being followed. Findings will be reported to the QAPI committee.
- Root cause analysis completed.
Improper Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation and food handling practices, as observed in the kitchen and one of the serving areas, potentially affecting 44 residents. In the kitchen, garbage cans were found to be very soiled, and one was missing a lid near a food preparation area. Multiple food items, including a chef salad, cold cuts, fruit salad, jello, and cake, were found undated and uncovered in the refrigerator and walk-in refrigerator. Additionally, scoops were improperly stored inside bulk food bins containing flour, sugar, oatmeal, and bread crumbs, despite having designated holders. The handwashing sink in the kitchen was also noted to be very dirty. On a subsequent observation, scoops were again found improperly stored in food bins for oatmeal and food thickener. In the second-floor serving area, a mop and bucket with dirty water were placed next to a food service cart, and the sink was observed to be very dirty. The facility's policies on dining cleaning and storage were reviewed, which stated that waste receptacles should be cleaned weekly and that scoops should not be stored in food, with food items needing to be dated. These findings were communicated to the Administrator and Director of Nursing.
Inadequate Telephone Access for Second-Floor Residents
Penalty
Summary
The facility failed to ensure that residents on the second floor had reasonable access to telephones in a private setting. While residents on the first floor had telephones in their rooms, those on the second floor did not. Instead, a single phone was available at the end of the hallway, which did not provide privacy. This issue was highlighted during a Resident Council meeting where a resident expressed dissatisfaction with the lack of phones in second-floor rooms. The Nursing Home Administrator (NHA) explained that the facility had previously disconnected the phone systems on the second floor, anticipating no residents would reside there. However, residents were now living on the second floor, and the facility had not yet reinstated adequate phone access. During a surveyor's walk-through, it was observed that only two cordless telephones were available for 28 residents on the second floor, with one being inoperable. A Registered Nurse (RN) on the second floor confirmed the limited phone access and mentioned that she often used her personal cellular phone to facilitate private calls for residents, as the facility's landline was located in the nurse's station, which did not allow for privacy. The RN indicated that additional cordless telephones would be beneficial, as using her personal phone was not ideal. The surveyor informed the NHA and Director of Nursing (DON) of these findings, but no further information was provided on why the facility had not ensured adequate telephone access for second-floor residents.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident who was observed self-administering Diclofenac gel and Nystatin powder without a proper assessment or physician's order. The facility's policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medications, along with a prescriber's order. However, the resident's medical record lacked both the necessary assessment and physician's order, and there was no documentation on the care plan regarding self-administration of medication. During a medication pass observation, an LPN confirmed with the resident that they had already self-administered the medications, and subsequently marked them as administered on the Medication Administration Record (MAR). The Nursing Home Administrator later acknowledged that the assessment had not been completed, although it was intended to be done. The Acting Director of Nursing confirmed that the assessment and interdisciplinary review were conducted the following day, and a physician's order was requested. The surveyor informed the facility of these concerns during the daily exit meeting.
Failure to Notify Representative and Physician After Resident's Fall
Penalty
Summary
The facility failed to notify a resident's representative and attending physician of a change in condition following a fall with injury. The resident, identified as R45, was admitted with multiple diagnoses, including a displaced intertrochanteric fracture of the right femur and severe cognitive impairment. On the night of the incident, R45 fell and was subsequently transported to the hospital with a left hip fracture and brain bleed. Despite the severity of the incident, there was no documentation indicating that the resident's representative or attending physician was informed of the fall and subsequent hospitalization. The deficiency was identified during a surveyor's review of the electronic medical record, which revealed the absence of any notification to the family or physician after the fall. The agency nurse who attended to R45 and facilitated the hospital transfer could not recall notifying the family or physician. The Interim Director of Nursing confirmed the lack of documentation regarding the notification. The issue was brought to the facility's attention during the daily exit meeting, but no further information was provided to address the concern.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was fully informed and consent was obtained for the administration of psychotropic medications. R37, who has a history of stroke, aphasia, lung cancer, and adjustment disorder with mixed anxiety and depressed mood, was prescribed Trazodone and Mirtazapine. Despite the resident's severe cognitive impairment and inability to communicate effectively, the facility did not secure written consent from R37's Power of Attorney (POA) for these medications. The facility's policy requires informed consent to be reviewed and signed by the individual or responsible party, which was not adhered to in this case. The deficiency was identified during a survey when the surveyor reviewed R37's medical records and found no documentation of informed consent for the prescribed medications. The Director of Nursing (DON) acknowledged the oversight and confirmed that consent had not been obtained. The Nursing Home Administrator was informed of the issue, but no further information was provided regarding corrective actions at the time of the survey. This oversight indicates a failure to comply with the facility's protocol for obtaining informed consent for psychoactive medications, potentially impacting the resident's right to be informed about their treatment options and associated risks.
Failure to Protect Resident's Property from Loss
Penalty
Summary
The facility failed to ensure a safe, home-like environment by not adequately protecting a resident's property from loss. A resident, who is cognitively intact with a BIMS score of 15, reported that two of her shirts went missing after being sent to the facility's laundry department. Despite the resident filling out a form with the description of the missing shirts, the facility did not follow through in a timely manner to locate the items. The resident had brought up the issue during a resident council meeting, but the facility staff assumed the issue was resolved without confirming the recovery of the shirts. Interviews with facility staff revealed a lack of clear protocol and communication regarding the handling of missing items. A CNA mentioned that they would inform a nurse and a supervisor about missing items, but was unaware of the subsequent steps if the items were not found. The Assistant Director of Nursing indicated that a grievance should be filed if items are not located, but no grievance was found in the records. The Social Worker also assumed the issue was resolved after the resident council meeting. The facility did not provide a policy on missing items when requested by the surveyor, highlighting a gap in the facility's procedures for addressing such issues.
Failure to Review and Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to ensure that a baseline care plan was reviewed with a resident and a copy or summary of the plan was provided within 48 hours of admission, as required by their policy. The resident, identified as R10, was admitted with diagnoses including chronic heart failure, weakness, unsteadiness on feet, and chronic kidney disease. Despite having a BIMS score indicating cognitive intactness, R10 reported not participating in the baseline care planning process and not receiving any information about it. The medical record lacked documentation of a signed baseline care plan, contrary to the facility's policy. Interviews with the Acting-Director of Nursing and Interim-Director of Nursing revealed that the facility had a process and policy for completing and reviewing baseline care plans, but it was not followed in this instance. The baseline care plan was supposed to be completed, reviewed with the resident, signed, and scanned into the medical record within two days of admission. However, this process was not adhered to, as evidenced by the absence of a signed care plan in R10's medical record. The Nursing Home Administrator was informed of this deficiency, but no further information was provided.
Failure to Implement Pressure Injury Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R100, who was at risk for pressure injuries. R100 was admitted with diagnoses including diabetes, muscle weakness, and urinary incontinence. The resident's Admission Minimum Data Set (MDS) indicated a risk for pressure injuries, triggering a Care Area Assessment (CAA) for Pressure Injury. Despite this, the resident's care plan did not include any measures for the prevention of pressure injuries, even though the Braden Scale for Predicting Pressure Ulcer Risk had documented the resident as being at risk on multiple occasions. During the survey, it was observed that R100 was using a pressure reduction mattress and had her heels elevated, yet no pressure injuries were noted. However, the Director of Nurses (DON) confirmed that there was no care plan in place for the prevention of pressure injuries, which was a requirement according to the facility's policy. This deficiency was discussed with the Nursing Home Administrator and the DON during the exit meeting, but no additional information or corrective actions were provided at that time.
Deficiency in ADL Care for Two Residents
Penalty
Summary
The facility failed to provide necessary ADL services for two residents, R8 and R31, who were dependent on staff for assistance. R8, who has severe cognitive impairment and multiple medical conditions, was observed with long, dirty fingernails and was scratching open wounds on her leg and head. Despite being dependent on staff for all ADLs, there was no documentation of nail care being performed, and staff were unsure if nail care was included in R8's care plan. The facility's policy indicated that nail care should be done on bath days, but this was not consistently documented or performed for R8. R31, also with severe cognitive impairment and multiple diagnoses, was observed with contracted fingers and long, dirty fingernails that were touching the palms, posing a risk of injury. R31's care plan included interventions for skin integrity but did not specifically address nail care. Staff indicated that nail care was typically done on bath days, but there was no evidence that this was being completed for R31. The hospice aide noted the need for nail care but did not perform it, and there was no documentation of nail care being done on scheduled bath days. The surveyor's observations and interviews with staff highlighted a lack of consistent nail care for both residents, despite the facility's policy and the residents' dependency on staff for ADLs. The interim DON and NHA were informed of the concerns, but no immediate corrective actions were documented in the report. The deficiency in providing adequate ADL care, specifically nail care, was evident in the facility's failure to ensure proper hygiene and prevent potential harm to the residents.
Deficiency in Weekend Activities Program
Penalty
Summary
The facility failed to provide an ongoing, individualized, and meaningful activities program designed to meet the residents' interests and support their physical, mental, and psychosocial well-being for two residents reviewed for activities. Both residents expressed a desire to participate in organized group activities on the weekends, but the facility did not offer such activities. Instead, the facility provided activity packets and options to watch sports or church services on television, which did not meet the residents' needs for group interaction. The facility's activity calendars for March, April, and May confirmed the lack of organized group activities on weekends. Additionally, the facility did not complete Section F of the Minimum Data Set (MDS) assessment for one of the residents, which is intended to document the importance of activities and the types of activities the resident would enjoy. The Life Enrichment Director acknowledged the deficiency in weekend activities and the incomplete MDS section, attributing the lack of weekend activities to staffing limitations. The Director of Nursing and the Nursing Home Administrator were informed of these concerns, but no policy regarding resident activities was provided to the surveyor.
Failure to Implement Timely Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate assistance devices and interventions were in place to prevent accidents for a resident identified as high risk for falls. The resident was admitted to the facility after experiencing a fall with head trauma at a previous residence and was assessed as a high fall risk upon admission. Despite this, a falls care plan was not initiated until nearly two months later, on December 4, 2023. During this period, the resident experienced multiple falls, including an incident where the resident was lowered to the floor by staff after losing balance while attempting to prepare for a shower. The resident's care plan was not revised following subsequent falls on December 8 and December 12, 2023, which indicated a need for more frequent safety checks and encouragement to use the call light for assistance. The resident had a history of self-transferring and not using the call light, which contributed to the falls. Despite being reminded to call for assistance, the resident continued to self-transfer, leading to further incidents. The facility's failure to update the care plan and implement effective interventions contributed to the ongoing risk of falls. Interviews with staff revealed that the resident preferred to be independent and was generally compliant with using the call light in recent months. However, the lack of timely and appropriate interventions in the care plan following the initial and subsequent falls demonstrated a deficiency in the facility's approach to fall prevention for this high-risk resident. The surveyor noted these deficiencies and shared concerns with the facility's administration, highlighting the need for a more proactive approach to fall prevention and care plan management.
Deficiency in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a valid medical justification for its continued use, appropriate monitoring, and care to maintain dignity. The resident, identified as R31, was admitted with a Foley catheter but lacked a diagnosis or justification for its use, as well as orders for monitoring or care instructions. Observations revealed that the catheter bag was not placed in a privacy bag, exposing it to view. The facility's policy required obtaining an order for the catheter, documenting its type, size, and indication for use, and involving the resident or responsible party in the care plan process, none of which were followed. The resident, R31, had multiple diagnoses, including anxiety disorder, dysphagia, and quadriplegia, and was on hospice care requiring consistent oxygen. Despite these conditions, there was no catheter care plan or interventions listed for the certified nursing assistant (CNA) to follow. The CNA reported emptying the catheter bag regularly but was unsure about changing the bag or cleaning the insertion site. The licensed practical nurse (LPN) confirmed the absence of catheter care orders in the resident's medical record and was uncertain about when the catheter and bag were last changed, suspecting that hospice might have handled it. The nursing home administrator was informed of these issues, but no immediate corrective actions were documented in the report.
Deficiency in Respiratory Care for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for a resident requiring oxygen therapy. The resident, who has multiple diagnoses including chronic obstructive pulmonary disease and is on hospice care, was observed with unlabeled oxygen tubing and without protective coverings around the ears as per the facility's respiratory protocol. Additionally, there was no care plan in place for the resident's respiratory or oxygen use, and no specific orders for the care of oxygen supplies were documented. During the survey, it was noted that the resident's oxygen was running at 5 liters, but the nasal cannula was not properly positioned in the resident's nose. Staff interviews revealed a lack of clarity and consistency regarding the replacement and labeling of oxygen equipment. The interim DON acknowledged the need for labeling and regular replacement of oxygen tubing but was unsure of the standard practice. The CNA and LPN interviewed were also uncertain about the specific care requirements and procedures for the resident's oxygen use, indicating a gap in staff training and protocol adherence.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for two residents, R7 and R34, as observed during a medication pass. For R34, Hydrochlorothiazide 12.5 MG was not administered because it was not found in the medication cart, yet it was signed out as given on the Medication Administration Record (MAR). The Licensed Practical Nurse (LPN) responsible for administering the medication admitted to not finding it in the cart and thus not giving it, despite it being recorded as administered. Similarly, for R7, Voltaren gel was not administered because it had been used up the previous day and not reordered. The agency nurse involved in the medication pass acknowledged that the medication was not available and had not been reordered, yet it was signed out as administered by the LPN they were training. The facility's Acting Director of Nursing and Interim Director of Nursing confirmed that both medications were available in the Omnicell system and should have been administered, highlighting a failure in following the facility's procedures for medication administration and documentation.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of psychotropic medications for two residents, leading to deficiencies in medication management. One resident, identified as R6, was prescribed Duloxetine for depression without a corresponding care plan or monitoring for depressive symptoms and side effects. Despite having intact cognition and no depressive symptoms according to their quarterly MDS, there was no documentation or specific monitoring in place to assess the effectiveness or side effects of the medication. The facility's staff, including CNAs and LPNs, were not aware of any specific monitoring requirements for R6, and the care plan lacked any mention of the antidepressant medication. Another resident, R37, was receiving Trazodone and Mirtazapine for anxiety and appetite, respectively, but there was no behavior monitoring to ensure the effectiveness of these medications. Although a care plan was eventually initiated, it was not specific to the anti-anxiety medication, and there was no documentation of behavior monitoring in the resident's TAR or MAR. Interviews with nursing staff revealed a lack of awareness and documentation regarding behavior monitoring, which was necessary to evaluate the effectiveness of the psychotropic medications. The facility's policy on psychoactive medication protocol was not adequately followed, as it required monitoring of medication side effects and documentation of target behaviors. The surveyor's findings highlighted the absence of specific care plans and monitoring for residents on psychotropic medications, which are essential to ensure the medications are necessary and effective. The facility's failure to implement these measures resulted in a deficiency in the medication regimen for the residents involved.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.11% during a survey. Three residents were affected by this deficiency. One resident did not receive Voltaren Gel as ordered, despite it being signed out on the Medication Administration Record (MAR). The agency nurse acknowledged that the gel was used up the previous day and not reordered, and it was revealed that the medication was available in the facility's Omnicell system but was not administered. Another resident did not receive Hydrochlorothiazide 12.5 mg, which was also signed out on the MAR. The LPN responsible for administering the medication stated that it was not found and therefore not given, although it was available in the Omnicell system. A third resident did not receive Amlodipine 10 mg, despite it being signed out as administered. During the medication pass, the surveyor observed that the medication was not included in the medication cup, although it was an active physician order. The surveyor confirmed with the nurse that the medication was not administered, leading to a discrepancy in the MAR. These incidents highlight a failure in the facility's medication administration process, as medications were either not reordered, not located, or not administered despite being available, and were inaccurately documented as given.
Resident Received Double Dose of Vancomycin Due to Transcription Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident, identified as R100, was admitted with a diagnosis that included status post right knee surgery. The resident had a physician's order for Vancomycin 125 milligrams for an infection in the right knee to be administered every three days. However, due to a transcription error, the order was duplicated, resulting in the resident receiving double the prescribed dose from April 12, 2024, to May 28, 2024. This error led to the administration of 16 extra doses of Vancomycin during this period. The issue was identified by a surveyor on May 28, 2024, and brought to the attention of the Nursing Home Administrator and Director of Nurses. Upon review, no negative effects from the extra doses were found in the resident's medical record.
Deficiencies in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to currently accepted professional principles, as well as failed to remove expired medications from medication carts. This deficiency was observed in 3 out of 5 medication carts/storage rooms. Specifically, the refrigerators in the 1st and 2nd floor medication storage rooms lacked temperature monitoring logs, which are necessary to ensure medications are stored within the appropriate temperature range. The surveyor noted the absence of a temperature log in the 2nd floor medication storage room and an incomplete log in the 1st floor medication storage room, with only a few dates filled out for the month of December. The Interim Director of Nursing confirmed that temperature logs were not being maintained and indicated that the facility would begin recording temperatures immediately. Additionally, the surveyor observed that a vial of insulin glargine, which was opened on March 15, 2024, was still being stored in the medication cart beyond its recommended use-by date. According to Diabetes.org, once opened, insulin vials should be stored at room temperature for no more than 28 days before being discarded. Despite this guideline, the insulin glargine was still present in the medication cart during the surveyor's review on May 29, 2024. The surveyor confirmed that the resident had an active physician order for insulin glargine to be administered at bedtime for diabetes management.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data, including the date, resident census, and total actual hours worked by RNs, LPNs, and CNAs, was posted daily. This deficiency was observed when a surveyor noted that the nursing postings at the facility's main entrance were dated 5/30/2024, despite the survey being conducted on 6/3/2024. The surveyor's attempt to locate the responsible scheduler revealed a lack of clarity regarding who was responsible for updating the postings on weekends or when the scheduler was not present. During interviews, the scheduler admitted to forgetting to post the data on 5/31/2024 and expressed uncertainty about who updated the postings in their absence. The Nursing Home Administrator (NHA) was also unsure about the process for updating postings when the scheduler was unavailable. This lack of a clear procedure led to the failure to update the nurse staffing information daily, potentially affecting all 44 residents in the facility.
Failure to Prevent Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident who was admitted without a pressure injury was properly assessed and monitored, resulting in the development of a stage 3 pressure injury. The resident, who had diagnoses including Alzheimer's Disease, diabetes mellitus, chronic kidney disease, and transient ischemic attack, was admitted with no pressure injuries and was assessed with a BIMS score indicating severe cognitive impairment. Despite being identified as at risk for pressure injuries, the resident's care plans did not include any interventions to prevent the development of pressure injuries. The Braden Scale completed on admission indicated no risk, but no further skin assessments were documented until the wound was identified by a wound care specialist, who noted the injury was over seven days old. The resident was later transferred to the hospital for an unrelated reason and did not return to the facility. The facility's policy required weekly skin checks and documentation, but there was no evidence of these checks being completed for the resident. Progress notes and other medical records did not indicate any skin concerns or pressure injuries from admission until the wound was identified. Interviews with staff, including an LPN and the ADON, revealed a lack of awareness of the pressure injury, and the facility was unable to provide additional information regarding the development of the injury. The administrator confirmed the absence of further information prior to the wound's identification.
Inaccurate Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately documented throughout the medical record. The resident, who was under hospice care and had a terminal prognosis, was documented as a Full Code in the electronic medical record (EMR) despite having a Do Not Resuscitate (DNR) order since 10/02/22. This discrepancy was discovered when the resident's family member found the resident nonresponsive and informed the nurse on duty of the DNR status. The nurse, following the EMR, indicated the resident was a Full Code and required the family member to sign another DNR form. The facility's Administrator confirmed the inconsistency in the resident's code status documentation during an interview.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to complete a thorough investigation of a fall involving a resident (R5) who was admitted with diagnoses of Alzheimer's Disease, unsteadiness on feet, and muscle weakness. The resident, who was severely cognitively impaired and required moderate assistance with most activities of daily living, was found sitting on the floor in her room without socks or shoes. The fall was unwitnessed, and the resident reported that she had slipped down onto the floor. Despite this incident, the facility did not document the fall in the Incident Report, and numerous attempts to contact the nurse on duty at the time were unsuccessful. The Assistant Director of Nursing (ADON) confirmed that she had made multiple calls and texts to the nurse but had not received any response. The Administrator also confirmed that there was no additional information or investigation conducted by the risk committee regarding the fall. This lack of documentation and follow-up investigation is a violation of the facility's policy, which requires a thorough review and root cause analysis by the Interdisciplinary Team (IDT) for any fall incidents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R3) who was frequently incontinent of bowel and bladder. R3, who was moderately cognitively impaired and required maximum assistance for toileting, was observed on multiple occasions with wet pants and a saturated brief. Despite the facility's policy to check and change residents every two to three hours, R3 was left in wet clothing for an extended period, from at least 12:40 PM to 2:10 PM, without being checked or changed. The CNA responsible for R3 admitted to not checking him for incontinence since 10:00-10:30 AM, citing understaffing as the reason for the lapse in care. This neglect was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that residents should be checked every two hours. The observations and interviews revealed that R3's incontinence care was not managed according to the facility's protocol, putting the resident at risk for skin issues and potentially a urinary tract infection. The resident's care plan specifically required cleaning after every incontinence episode and monitoring for signs of urinary tract infection, which was not adhered to. The CNA's failure to check and change R3 in a timely manner, combined with the facility's staffing issues, directly led to the deficiency in care.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during incontinence care for one resident. During an observation, a CNA did not change her gloves after removing the resident's soiled clothing and before putting on a clean brief. The CNA continued to use the same gloves to clean the resident's perineal area, apply a clean brief, and change the resident's oxygen tubing. This action was against the facility's hand hygiene policy, which mandates glove removal and hand hygiene before moving from a soiled body site to a clean body site and immediately after glove removal. The resident involved was admitted with diagnoses of right hemiplegia, Alzheimer's disease, and dementia, and was assessed as moderately cognitively impaired. The resident required maximum assistance for toileting and was frequently incontinent of bowel and bladder. The CNA acknowledged her mistake immediately after the observation, and the Assistant Director of Nursing confirmed that the CNA should have changed her gloves between handling the soiled brief and the clean brief.
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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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