Little Chute Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Little Chute, Wisconsin.
- Location
- 1201 Garfield Ave, Little Chute, Wisconsin 54140
- CMS Provider Number
- 525579
- Inspections on file
- 30
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Little Chute Health Services during CMS and state inspections, most recent first.
A resident admitted after major cervical spine surgery with multiple comorbidities, including DM and CHF, experienced a progressive change in condition over several days, including hypoxia requiring O2, decreased cognition, hypoglycemia, abnormal VS, poor PO intake, and cough. Documentation showed low O2 sats, blood glucose of 45 with involuntary movements, abnormal VS, decreased food and fluid intake, and increasing confusion and drowsiness. Despite family concerns about the resident’s confusion and poor intake, and the resident later being unarousable when an RN attempted to give medications, the RN did not complete a full assessment, did not check blood glucose, and did not promptly notify a provider. EMS was called by family, found a blood glucose of 42, and the resident was hospitalized with severe hypoglycemia with coma, sepsis secondary to acute cystitis, depressed GCS, and acute kidney injury. Surveyors cited this as a failure to recognize and appropriately respond to a change in condition, resulting in immediate jeopardy.
A resident with quadriplegia, dysphagia, and a history of aspiration had a care plan and therapy orders requiring pureed diet with honey-thick liquids, upright positioning as close to 90° as possible, use of a neck pillow, and 1:1 supervision during all meals. Despite prior documented coughing with food, abnormal lung findings, hospitalization for aspiration-related pneumonia and sepsis, and repeated ST and OT recommendations for strict swallowing precautions and total supervision, the resident was observed eating breakfast alone in bed at about 45°, without a neck pillow, with food on the dignity cover and liquid spilling from the mouth, and after several deep, congested coughs. No staff were present in the room or hallway, and staff interviews confirmed that they typically only set up meals and checked every 15–20 minutes, even though the Kardex and DON acknowledged the need for direct supervision, resulting in a deficiency for failure to provide adequate supervision and safe positioning during meals.
Two residents did not receive appropriate pressure ulcer prevention and treatment. One high-risk resident was admitted without documented pressure injuries, but no skin integrity care plan or ongoing skin assessments were implemented, and staff later reported unassessed coccygeal dressings and zinc application; the resident was subsequently hospitalized with multiple deep tissue pressure injuries to the sacrum, thigh, and heel that the facility had not identified. Another resident admitted with a stage 4 sacral pressure injury had an order and care plan for an alternating air mattress set to 250 lbs, but surveyors twice observed the mattress set at 350 lbs, once on static mode, while staff TAR entries incorrectly documented the setting as appropriate despite manufacturer guidance that the setting should approximate the resident’s actual weight.
A resident with vascular dementia, hemiplegia, cerebral infarction, diabetes, and severe cognitive impairment was not seen by a physician within the required time frames following admission, contrary to facility policy requiring MD visits at least every 30 days for the first 90 days. The initial post‑admission visit was completed by an APNP instead of a physician, and subsequent MD visits were spaced such that a required visit was missed, as confirmed by the NHA through record review and interview.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk of accidents for residents.
A resident with severe cognitive impairment and right-sided hemiplegia required specialized care techniques during ADLs, such as step-by-step explanations, gentle handling, and breaks to prevent pain and frustration. Staff interviews confirmed these needs, but the care plan did not include detailed, person-centered interventions reflecting these requirements.
A resident with quadriplegia, dependent on staff for ADLs, repeatedly requested nail care that was not provided despite documented care plans and nursing orders. Staff interviews and observations confirmed that the resident's fingernails remained untrimmed for several days, and there was no specific facility policy or documentation for nail care. The resident expressed dissatisfaction with the condition of their nails.
Two residents were not monitored for adverse reactions to high-risk medications, including a diuretic prescribed for edema and an antibiotic administered during dialysis. The facility's own policies require monitoring for adverse consequences, but documentation and care plans did not reflect this for either resident, as confirmed by the DON.
A resident dependent on staff for feeding received meals that were often left on the bedside table for extended periods, resulting in food and drink being served at unappetizing and unsafe temperatures. Staff confirmed that all trays were delivered before feeding assistance began, and the DON was unaware of concerns regarding meal temperatures or delays.
Staff did not follow enhanced barrier precautions for a resident with a Foley catheter and PEG tube, failing to wear required PPE such as gowns during high-contact care activities and not posting an EBP sign at the resident's door. Staff interviews revealed confusion about the resident's precaution status, and the deficiency was confirmed by the DON.
The facility failed to ensure accurate labeling of medications for two residents. One resident received furosemide 40 mg with a medication card labeled incorrectly as one tablet daily instead of twice daily. Another resident received metoprolol succinate ER 50 mg with a medication card labeled incorrectly as 25 mg twice daily instead of 50 mg once daily. These errors were confirmed by the LPN and DON.
Failure to Recognize and Respond to Resident’s Multi‑Day Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to recognize and appropriately respond to a resident’s change in condition over several days following admission after major spinal surgery. The resident was admitted after a C3–C4 laminectomy with diagnoses including cervical spondylosis, diabetes, hypertension, hypothyroidism, atrial fibrillation, and congestive heart failure. On admission, the resident was documented as alert and oriented x4, able to make needs known, with clear lungs on room air and a patent Foley catheter draining clear amber urine. The facility’s policy on change in condition required staff to assess the need for immediate care, provide emergency care as needed, and evaluate the resident, including vital signs, oxygen saturation, blood glucose, and alterations in level of consciousness, and to notify the physician immediately for acute or sudden onset symptoms. Beginning the day after admission, the resident showed multiple documented changes in condition. Progress notes indicated the resident became drowsy and hard of hearing, with the diet downgraded to pureed per the resident’s choice and medications crushed due to swallowing difficulty. On one night, the resident’s oxygen saturation dropped to 79%, improving only to 84% after deep breathing, leading to an order for supplemental oxygen at 2–5 liters, and the resident was placed on 2 liters. Subsequent notes described the resident sleeping throughout a shift, being only alert and oriented x2, spending a lot of time sleeping, and having blood glucose of 45 with involuntary jolting arm movements consistent with hypoglycemia, requiring two doses of 40% glucose gel. A change in condition evaluation documented abnormal vital signs, decreased food and fluid intake, and other changes such as talking less, being tired, weak, confused, and drowsy. Additional notes recorded a slight cough, low blood pressure of 94/52 with an order to hold hydralazine, continued need for 2 liters of oxygen with oxygen saturation at 93%, poor eating, sips of orange juice through the night, and a productive cough with mucus. Despite these ongoing changes, the facility did not initiate and follow through with an appropriate change in condition response. During a care conference, the resident’s family reported concerns about the resident’s eating, confusion, and overall medical condition to the DON. The following morning, when an RN obtained the resident’s vital signs, the blood pressure was 102/53, and the RN attempted to administer medications in pudding but was unable to arouse the resident, who did not drink or open their eyes. The RN left the room and did not return, did not perform a further assessment, did not check the resident’s blood sugar, and did not promptly notify medical staff, despite the family member’s expressed concern that the resident was not eating or drinking and appeared unresponsive. The family member later informed the RN they were going to call 911. When EMS arrived and asked about the resident’s blood sugar, facility staff reported they did not know. EMS found the resident’s blood sugar to be 42, and the resident was subsequently admitted to the hospital with diagnoses including severe hypoglycemia with coma requiring emergent IV glucose administration, sepsis secondary to acute cystitis, depressed Glasgow Coma Scale with decreased responsiveness, and acute kidney injury. The surveyors determined that the facility failed to recognize and appropriately respond to the resident’s change in condition over several days, leading to a finding of immediate jeopardy.
Removal Plan
- Reviewed current residents with like diagnoses to ensure appropriate monitoring and interventions were in place.
- Reviewed residents' progress notes and vital signs to identify residents with a potential change in condition that required provider notification, care plan changes, or additional monitoring.
- Educated licensed nurses on the need to promptly recognize, assess and report a change in condition, including the importance of implementing appropriate follow-up monitoring.
- Educated CNAs on recognizing and reporting changes in condition to a licensed nurse.
- Initiated audits to ensure monitoring protocols are in place for new admissions with diabetes.
- Initiated audits of nursing documentation to ensure changes in condition are promptly identified, pertinent and accurate medical information is communicated to the physician, and appropriate monitoring interventions are implemented.
Failure to Provide Required 1:1 Supervision and Safe Positioning During Meals for Aspiration-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, positioning, and use of assistive devices during meals for a resident with a known history of aspiration. The resident had diagnoses including quadriplegia, dysphagia, expressive aphasia, and anxiety, and required mechanically altered textures and thickened liquids. The resident’s comprehensive care plan, revised in late November, specified 1:1 supervision for all meals, encouragement of small bites and clearing the mouth before the next bite, sealing lips around the cup opening until swallowing was completed, use of a neck pillow for proper neck positioning for all meals, and upright positioning in a wheelchair for meals. The facility’s Dining Experience policy also required individuals to be positioned upright as close to 90 degrees as possible when eating in bed and to receive appropriate cueing and assistance to promote safe swallowing. Prior to the surveyor’s observation, there were documented indications of swallowing and respiratory concerns that were not fully acted upon. On one date in November, a progress note recorded that the resident coughed and had food coming out of the mouth during lunch; staff elevated the head of the bed, assisted with finishing the meal, and provided cues for small bites and clearing the mouth, but the LPN who documented the event did not notify the physician and was unsure if anything further was done. The APNP later stated they had not been notified and would have wanted respiratory assessments at least each shift. In mid-December, the resident reported that their lungs felt funny, had crackles on lung assessment, vomited during the night, and later that day had abnormal vital signs and lung sounds with rhonchi, leading to transfer to the hospital. Hospital records showed the resident was treated for aspiration-related right lower lobe infiltrate and septic shock, and an OT evaluation there reiterated the need for upright positioning, one sip or bite at a time, alternating liquids and solids, and 1:1 supervision during meals. Speech therapy documentation before and after the hospitalization reinforced the need for strict swallowing precautions. A speech therapy progress note in early December indicated the resident required prompting to improve oral containment and bolus management, with safety precautions such as upright posture emphasized to staff. A speech therapy evaluation at the end of December recommended pureed texture, honey-thick liquids, eating in a wheelchair with total supervision, and upright positioning during meals and for at least 30 minutes afterward. A treatment note in mid-January confirmed the resident remained on a pureed diet with honey-thick liquids and required total supervision while upright for meals. A videofluoroscopic swallow study reviewed by the speech therapist showed airway invasion by nectar-thick liquids and poor posture with inability to sense penetration/aspiration. Despite these documented needs and care plan directives, on the morning of January 15 the surveyor observed the resident eating breakfast alone in bed with the head of the bed at approximately 45 degrees and without the prescribed neck pillow. The surveyor heard several deep, congested coughs before the resident’s airway cleared and then observed a large amount of food on the resident’s dignity cover and juice spilling from the right side of the mouth. No staff were present in the room or in the hallway, and the resident indicated that staff had not been in the room to assist or check since breakfast began and that staff did not usually sit in the room to provide supervision during meals. CNAs assigned to the wing reported that they assisted with meal setup and checked on the resident every 15–20 minutes, and the RN confirmed the resident should be directly supervised when eating, as indicated on the Kardex, but also stated the resident typically ate in the room. The DON verified that staff should be with the resident when eating in the room and should watch for signs and symptoms of aspiration. These observations and interviews demonstrated that the facility did not follow its own policy, the resident’s care plan, or therapy recommendations for 1:1 supervision, upright positioning, and use of a neck pillow during meals, leading to a finding of immediate jeopardy beginning on January 15.
Removal Plan
- Reviewed R2's care plan, dietary orders, and ST recommendations and made appropriate updates and revisions.
- Reviewed residents to identify those who require supervision, assistance, cueing, or monitoring during meals due to aspiration risk.
- Educated staff on R2's care plan and supervised meals and snacks for residents at risk for choking or aspiration.
- Instructed nursing staff to verify diet orders and supervision levels prior to serving meals, document the supervision provided, and report swallowing concerns and condition changes.
- Observed meal service to ensure compliance with supervision recommendations.
- Conducted record review and observation audits to ensure ST recommendations are documented in residents' care plans and followed by staff.
Failure to Prevent New Pressure Injuries and Mismanagement of Therapeutic Air Mattress Settings
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services to prevent the development of avoidable pressure injuries and to promote healing of existing pressure injuries for two residents. One resident was admitted without any documented pressure injuries, with an admission Braden Scale score of 15 indicating high risk for pressure injury development. Admission documentation and hospital transfer orders listed only a cervical surgical incision and bruising on the hands, antecubital area, and wrists, with no sacral, thigh, or heel wounds noted. Despite the high-risk Braden score, the initial care plan created on the day of admission did not include a focus area or interventions for skin integrity, and a skin integrity care plan was not initiated until nearly two weeks later, after the resident had already been transferred to the hospital. Nursing documentation from admission through the date of hospital transfer did not include ongoing skin integrity assessments beyond the initial Braden assessment. During this same period, staff interviews revealed gaps and inconsistencies in skin assessment and monitoring. A registered nurse reported performing a head-to-toe assessment on admission and stated that the coccyx would have been assessed only if wounds were documented on the Braden assessment, and did not recall whether a specialty mattress was used. A CNA reported that the resident had a bowel movement several days after admission and that there was a dressing on the coccyx at that time, but did not know who applied it and stated it was not removed during care. Another nurse recalled assisting with repositioning and stated that zinc was applied to the coccyx but did not recall any specific skin injuries. The DON stated that staff had documented no wounds other than the surgical incision on admission and was not aware that a dressing had been applied to the coccyx or that a skin integrity care plan focus area was only added after the resident’s hospitalization. When the resident was admitted to the hospital, wound care documentation identified multiple pressure injuries that had not been recognized or documented by the facility. Hospital assessments described a bilateral sacral deep tissue pressure injury with serosanguineous drainage, a right posterior thigh deep tissue pressure injury, and a right heel deep tissue pressure injury, all measured and characterized in detail. An advanced practice nurse who had completed the facility admission assessment later reviewed the hospital wound photos and documentation and stated that the coccyx wound appeared older than 24 hours, while the age of the thigh and heel wounds was uncertain. The facility was unaware of these pressure injuries prior to the hospital admission, and no ongoing skin integrity monitoring or targeted interventions had been documented during the resident’s stay. The second resident was admitted with a documented stage 4 sacral pressure injury and had a care plan and physician order for an air mattress set to 250 pounds on an alternating setting, along with a pressure redistribution cushion for the chair. The treatment administration record included an order for staff to check the function and setting of the air mattress every shift, with documentation that the mattress was set appropriately at 250 pounds. However, surveyor observations on two consecutive days showed that the air mattress was actually set at 350 pounds, first on an alternating mode and then on a static (non-alternating) mode, contrary to the care plan and orders. The most recent recorded weight for this resident was 156 pounds, and manufacturer guidance indicated that the mattress setting should be as close as possible to the resident’s current weight to ensure proper pressure relief. Despite these requirements, staff documentation in the TAR indicated that the air mattress was correctly set at 250 pounds on the shifts when surveyors observed it at 350 pounds and, on one day, in static mode. An LPN stated that staff were responsible for checking the air mattress setting each shift and documenting it, and that incorrect settings should be corrected and reported to the DON or wound nurse. The DON later confirmed that the mattress had been set too high and that it was not on the alternating mode as ordered. The discrepancy between the observed settings and the documented TAR entries, combined with the failure to match the mattress setting to the resident’s actual weight and prescribed alternating mode, demonstrates that the resident with a stage 4 sacral pressure injury did not receive care and services consistent with the care plan, physician orders, and manufacturer guidelines for pressure redistribution therapy.
Failure to Ensure Timely Required Physician Visits After Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident and physician met face-to-face at all required visits during the first 90 days after admission, as required by facility policy. The facility’s “Physician Visits and Physician Delegation” policy, revised 7/27/25, states that the physician should see a resident within 30 days of initial admission and that the resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission. Record review for one resident (R6), who was admitted on an unspecified date and had diagnoses including vascular dementia, hemiplegia, cerebral infarction, and diabetes, showed that R6 was not seen by a physician within 30 days of admission (including a 10‑day grace period) and was not seen every 30 days thereafter during the first 90 days. R6’s MDS dated 12/30/25 documented a BIMS score of 6/15, indicating severe cognitive impairment. The initial post‑admission visit was completed by an Advance Practice Nurse Prescriber (APNP) on 2/20/25 rather than by a physician, and subsequent physician visits occurred on 4/8/25 and 6/10/25, leaving a missed physician visit in May 2025. In an interview on 1/20/26, the Nursing Home Administrator confirmed that R6 was not seen by a physician for the initial visit and that a required physician visit was missing in May 2025. These findings show that, for this resident, the facility did not follow its own policy requiring timely, face‑to‑face physician visits within the first 90 days after admission, resulting in missed and delayed physician evaluations documented through staff interview and medical record review.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Care Plan Lacked Person-Centered Interventions for Resident with Right-Sided Deficit
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect the specific personal care needs of a resident with significant medical and cognitive impairments. The resident, who had a history of cerebral vascular accident with right-sided hemiplegia, dysphagia, aphasia, depression, cognitive communication deficit, and epilepsy, was assessed as having severe cognitive impairment. Multiple staff interviews revealed that the resident required specialized care techniques during activities of daily living, such as providing step-by-step explanations, working slowly and gently, offering breaks, and monitoring for signs of frustration or pain, particularly with right arm movement. Staff consistently described the need for these individualized approaches due to the resident's right-sided weakness, pain, and tendency to become anxious or frustrated during care. Despite these identified needs, the resident's care plan did not include detailed, person-centered interventions specific to the resident's care requirements. The care plan noted a right-sided deficit and a general intervention to explain activities prior to starting them, but it lacked instructions for providing care slowly and gently, offering breaks, and monitoring for increased frustration. Staff were unable to identify documentation of these specific actions in the care plan, and the plan did not fully address the specialized techniques necessary for the resident's safe and comfortable care.
Failure to Provide Timely Nail Care for Dependent Resident
Penalty
Summary
A resident with quadriplegia and an activity of daily living (ADL) self-care deficit was dependent on staff for personal hygiene, including nail care, as documented in the care plan and nursing orders. The resident's care plan specified the need for assistance with personal hygiene and highlighted the importance of careful nail trimming due to abnormal nails and build-up. Nursing orders required weekly nail care, and staff were expected to provide nail care on shower days. Despite these documented needs and requests, the resident reported asking multiple staff members to trim their fingernails over several days, including a specific request prior to leaving the facility for a family gathering. These requests were not fulfilled, and the resident's fingernails remained longer than preferred. Staff interviews confirmed that nail care was not provided as requested, and that there was no specific facility policy or routine documentation for nail care or grooming. The Director of Nursing confirmed that nail care should be completed on shower days, which were scheduled twice weekly for the resident. Observation by the surveyor confirmed that the resident's fingernails extended approximately two millimeters past the fingertip, and the resident expressed dissatisfaction with the lack of nail care, referring to their nails as "claws."
Failure to Monitor for Adverse Reactions to High-Risk Medications
Penalty
Summary
The facility failed to ensure that two residents were adequately monitored for adverse reactions to high-risk medications, as required by their own medication management and antibiotic stewardship policies. One resident with heart failure, hypertension, and diabetes was prescribed furosemide for edema, but there was no evidence in the medical record or care plan that staff monitored for adverse reactions to this diuretic. The Director of Nursing confirmed that monitoring should have been included in the care plan and acknowledged the facility was transitioning its monitoring process from medication administration records to care plans. Additionally, the facility did not have a specific policy for diuretic or heart failure management. Another resident with a history of intraspinal abscess, end stage renal disease, and dependence on dialysis was prescribed cefazolin, an antibiotic, to be administered during dialysis sessions. The medical record did not show any monitoring for adverse reactions to the antibiotic prior to a specific date, and the DON verified this omission. The facility's policies require ongoing monitoring for adverse consequences of medications, but this was not documented or performed for these two residents.
Failure to Serve Palatable and Appropriately Tempered Meals to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, who was dependent on staff for oral intake and at risk for nutritional status change, consistently received meals at unappetizing temperatures. The resident reported that meals were rarely served hot and were typically lukewarm, with meal trays left on the bedside table for up to an hour before staff were available to assist with feeding. Observations confirmed that meal trays were delivered to the resident's room and left unattended for extended periods before staff provided feeding assistance. Temperature checks revealed that milk on the breakfast tray was above the recommended holding temperature, and the resident confirmed that the food was not warm. Multiple staff interviews corroborated that all meal trays were distributed to residents before any assistance with eating was provided, resulting in delays for residents who required help. Staff acknowledged that several residents, including the affected resident, had reported their food becoming cold while waiting for assistance. The Director of Nursing stated there was no specific policy for feeding assistance and was unaware of the resident's concerns about meal trays being left out for extended periods.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
Staff failed to maintain an effective infection prevention and control program for one resident who was on enhanced barrier precautions (EBP) due to the presence of a Foley catheter and a percutaneous endoscopic gastrostomy (PEG) tube. The facility's policy required staff to don appropriate personal protective equipment (PPE), including gowns and gloves, during high-contact care activities such as transferring and device care. However, during observed care activities, staff only donned gloves and did not wear gowns while disconnecting the resident's tube feeding and transferring the resident. Additionally, there was no EBP sign posted on or near the resident's door to alert staff to the required precautions. Interviews with staff revealed a lack of awareness regarding the resident's EBP status, with some initially indicating the resident was not on precautions. The LPN and CNAs involved in the care confirmed that appropriate PPE was not used, and the absence of the EBP sign was acknowledged by both staff and the Director of Nursing. The resident involved had significant medical needs, including hemiplegia, dysphagia, and severe cognitive impairment, and was under orders for EBP due to the presence of indwelling medical devices.
Medication Labeling Errors
Penalty
Summary
The facility did not ensure all medications were labeled appropriately for two residents during medication administration. Resident 138 was administered furosemide 40 mg, but the medication card was labeled incorrectly as one tablet daily, while the physician's order stated it should be administered twice daily. This discrepancy was confirmed by the Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged the error in the medication card label. Similarly, Resident 8 was administered metoprolol succinate ER 50 mg, but the medication card was labeled incorrectly as 25 mg twice daily, whereas the physician's order indicated a 50 mg dose once daily. This error was also verified by the LPN and the DON. Both instances highlight the facility's failure to adhere to its Medication Ordering and Receiving From Pharmacy Provider policy, which mandates accurate labeling of prescription medications.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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