Luther Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 4545 N 92nd St, Milwaukee, Wisconsin 53225
- CMS Provider Number
- 525588
- Inspections on file
- 28
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Luther Manor during CMS and state inspections, most recent first.
Two residents at risk for pressure injuries did not receive consistent prevention and wound care services as required by facility policy and provider orders. For one resident with multiple comorbidities and severe cognitive impairment, weekly skin checks were frequently undocumented before a facility-acquired stage 3 sacral pressure injury developed, and subsequent sacral and hip wounds were not always treated as ordered, with delays in entering wound care orders and repeated failures to implement the wound care provider’s specific dressing and topical treatment recommendations. For another resident who developed bilateral heel pressure injuries, staff had not floated the heels prior to injury, weekly skin checks were often missing, repositioning was infrequent per interviews and observation, and a pressure-relieving air mattress was not provided until several days after the heel wounds were discovered.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with significant mobility impairments filed a grievance after a CNA refused to transfer them to bed near shift change, resulting in a one-hour wait. The facility failed to complete the grievance investigation, did not interview the involved CNA, and did not document or communicate the resolution, leaving required forms unsigned and the process incomplete.
A resident with CMV was prescribed IV ganciclovir, but a nurse incorrectly transcribed the order, entering an early stop date. This led to the resident missing five doses of the antiviral medication before the error was discovered by the Infection Disease Clinic.
A facility failed to obtain a written consent for the psychotropic medication Seroquel prescribed to a resident with Delusional Disorder. Despite the resident's cognitive intactness, the facility did not secure a signed consent from the activated HCPOA when the medication was first prescribed. The absence of a facility policy for obtaining consents contributed to this oversight, and verbal consent was only obtained after the surveyor's inquiry.
The facility failed to report three abuse allegations involving two residents and a resident-to-resident altercation to the State Survey Agency within the required timeframe. The incidents included a bruise of unknown origin, an alleged rape, and a physical altercation. Delays were attributed to a transition period and lack of awareness by the Nursing Home Administrator.
The facility failed to thoroughly investigate allegations of abuse and resident-to-resident altercations. A resident alleged being raped and sustaining blunt force trauma, but the facility did not collect necessary statements or report the incident to the State Survey Agency. In another case, one resident punched another, but the facility's investigation was incomplete and delayed. The facility's policy on reporting and investigating incidents was not followed, and the Nursing Home Administrator acknowledged the deficiencies.
A resident with mental health needs did not receive the specialized psychiatric rehabilitation services recommended by a PASARR Level 2 evaluation. The facility failed to update the resident's care plan and coordinate with the interdisciplinary team to address these needs. Staff interviews revealed a lack of awareness and action regarding the required services, and the facility did not submit a timely PASARR screen, delaying the identification of the resident's needs.
A resident admitted with a Level I PASARR for a short stay remained in the facility beyond the 30-day exemption without a timely Level II PASARR evaluation. Diagnosed with multiple mental health disorders, the resident required specialized psychiatric services, which were not identified until a delayed PASARR update. The facility's oversight was linked to communication issues and the activation of the resident's HCPOA.
A facility failed to update a resident's care plan to include specialized psychiatric rehabilitation services as recommended by a Level II PASARR evaluation. The resident, with multiple mental health diagnoses, was not provided with person-centered interventions tailored to their needs. Despite the facility's policy requiring regular care plan reviews, the resident's plan remained unchanged, focusing on perceived negative behaviors without addressing underlying causes.
A resident admitted with a left femur fracture and other conditions experienced inadequate discharge planning, despite a goal to transition to a less restrictive environment. The facility failed to provide consistent planning, with no documented referrals or updated assessments, leading to the resident's distress and dissatisfaction. Interviews revealed a lack of active efforts to facilitate a safe discharge, and the nursing home administrator was unaware of the deficiencies.
A resident with multiple health conditions, including hemiplegia and chronic kidney disease, did not receive timely incontinence care as per their care plan, resulting in a saturated incontinence product. The CNA admitted to not checking the resident every two hours, as required. The LPN/UM confirmed the expectation for two-hour checks, and the deficiency was reported to the NHA and DON.
A resident with a history of trauma and multiple mental health diagnoses did not receive an individualized care plan or specialized psychiatric rehabilitation services as required. The facility failed to update the resident's care plan with person-centered interventions, and the Medication Administration Record was not accurately completed. Interviews revealed the resident's distress and dissatisfaction with the care provided, highlighting the facility's failure to address the resident's mental health needs effectively.
A resident with severe protein malnutrition and dementia developed a pressure injury that was not promptly assessed or treated, leading to its worsening. The facility failed to adjust the care plan to address the resident's nutritional needs and implement preventative measures, resulting in a finding of immediate jeopardy.
A resident with severe protein malnutrition and dementia experienced significant weight loss and developed a stage 4 pressure injury due to the facility's failure to conduct comprehensive nutritional assessments and develop an individualized care plan. Despite the resident's poor oral intake and dementia, the facility did not revise the care plan or implement speech therapy recommendations, resulting in a finding of immediate jeopardy.
The facility failed to accurately report COVID-19 cases during an outbreak, with two residents not included in the infection line list. Additionally, there was a lack of signage to indicate the outbreak, and CNAs were observed not following proper hand hygiene practices during meal service. The Infection Preventionist admitted to oversight in correlating cases with the outbreak, and the Director of Nursing confirmed the expectation for proper hand hygiene, which was not met.
The facility failed to develop comprehensive care plans for residents, including those with smoking habits, chronic conditions, and medication needs. This led to deficiencies in addressing their medical, nursing, and psychosocial needs, as confirmed by interviews with facility staff and surveyor observations.
The facility failed to ensure medication storage rooms were free of expired medications, affecting two units. Expired sodium chloride irrigation bottles, Systane lubricant eye drops, and tear eye drop advance bottles were found. Additionally, a bottle of Lantus insulin for a resident was opened and not dated, with another expired bottle present. The responsibility for checking expired medications was shared among staff, but the facility did not ensure compliance with protocols.
The facility failed to monitor and reduce doses of psychotropic medications for several residents, as required by its policy. Residents on antipsychotic medications did not receive necessary AIMS assessments, and there was no evidence of attempted dose reductions for some residents. The facility's electronic system failed to trigger required assessments, and the lack of documentation was acknowledged by staff.
The facility failed to report two allegations of abuse or neglect to the State Survey Agency within the required timeframe. An accusation of abuse involving a resident was not reported to the NHA promptly, and a resident-to-resident altercation was not reported to the State Survey Agency. Additionally, the facility did not investigate or report an injury of unknown origin involving another resident who returned from hospitalization with a femur fracture.
The facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin for two residents. One resident returned from hospitalization with a femur fracture, but no investigation was conducted. Another resident was involved in an abuse allegation and a resident-to-resident altercation, both of which were inadequately investigated and reported. The facility did not provide sufficient documentation or follow proper procedures, leading to deficiencies in handling these incidents.
The facility failed to provide required written transfer notifications to three residents and their representatives when they were hospitalized. The nursing staff, responsible for these notifications, did not complete them, and the State Ombudsman was not informed. This oversight affected residents who were transferred due to changes in condition or medical issues.
A facility failed to accurately document a resident's behaviors in the MDS, despite progress notes indicating occurrences of wandering, agitation, and resistiveness. The MDS inaccurately reflected that these behaviors were not exhibited, and interviews revealed that the social worker responsible for the section did not complete it correctly, highlighting a need for staff training.
The facility failed to update care plans for three residents, leading to deficiencies in addressing their medical and psychosocial needs. A resident's care plan was not revised after a Foley catheter was removed, another's did not reflect the use of a condom catheter, and a third's lacked documentation for a compression sleeve. Staff interviews confirmed the oversight, despite facility policies requiring timely updates.
The facility did not act on pharmacist recommendations for two residents regarding the use of Seroquel without an appropriate diagnosis. Despite repeated pharmacy reviews noting this issue, no follow-up actions were taken by the facility, and the recommendations were not addressed by the physician.
A resident with a history of heart disease and hypertension did not receive six doses of Plavix due to medication unavailability, despite the facility having an Omnicell system. Staff interviews revealed inconsistencies in following procedures for obtaining medications, with the DON acknowledging the availability of Plavix in the Omnicell and indicating a need for further investigation.
A facility failed to ensure a CNA received the required 12 hours of continuing competence training, affecting 90 residents. CNA-M, hired in 2022, only completed 4.5 hours. The training department, responsible for tracking CNA training, overlooked CNA-M, as confirmed by interviews with the DON and NHA.
The facility failed to provide adequate care for pressure injuries, resulting in deterioration and severe outcomes for three residents. One resident's pressure injury progressed from a deep tissue injury to a Stage 4 wound due to delayed lab tests and incomplete antibiotic treatment. Another resident developed multiple pressure injuries, leading to an amputation. A third resident's pressure injury worsened due to lack of comprehensive assessment and care plan updates.
The facility failed to implement care plans for residents at high risk for falls, leading to significant injuries. One resident, admitted with a fractured hip, was assessed as high risk but had no care plan for falls, resulting in another fracture. Another resident experienced an unwitnessed fall with inadequate investigation and no new interventions. The facility did not follow its fall prevention policies, contributing to these deficiencies.
A resident was allegedly choked by a CNA, but the incident was not reported to the State Survey Agency or local law enforcement within the required timeframes. Another resident overheard the incident and attempted to report it, but the call light was not answered until hours later. The facility's report was submitted late, and the social worker could not explain the delay or lack of law enforcement notification.
The facility failed to thoroughly investigate abuse allegations involving two residents. In one case, a resident reported being choked by a CNA, but the investigation lacked comprehensive witness statements and a physical assessment. In another case, a resident reported verbal abuse, but the facility did not follow up with all staff or collect resident statements. Both investigations were incomplete, lacking critical documentation and analysis.
A resident with a femur fracture did not receive timely follow-up care as per discharge instructions. The facility lacked a policy for managing appointments, leading to delayed and missed orthopedic consults. Despite training to improve scheduling, the resident's care did not align with professional standards or their care plan.
Failure to Provide Consistent Pressure Ulcer Prevention and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and treatment consistent with its own policies and professional standards for two residents with, or at risk for, pressure injuries. For one resident on hospice with multiple comorbidities including vascular dementia, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and functional dependence, the facility did not consistently complete and document weekly skin checks as required by policy and medical orders in the weeks preceding the development of a facility-acquired stage 3 sacral pressure injury. In the eight weeks prior to the initial sacral wound, weekly skin checks were undocumented on four occasions, and when showers were refused, there was not always documentation of a completed skin assessment or of re-approach attempts, despite the DON’s expectation that skin checks still occur and be documented. After the sacral pressure injury developed, the facility did not consistently implement and document wound treatments as ordered by the physician and wound care provider. There were delays of two days in entering and starting treatment orders for new bilateral hip stage 2 pressure injuries, and on at least one day no treatment was documented as completed for these new wounds. For the sacral wound, staff documented using Santyl when the wound provider had changed the treatment to Leptospermum (Medihoney), and there were multiple days when the sacral wound was only cleansed and covered without the ordered topical agent due to Santyl being unavailable and the new order not yet implemented. When the left hip pressure injury reopened, the wound provider’s treatment recommendations were not entered as medical orders for several days, resulting in that wound going without the ordered daily treatments from the time of reopening until new orders were entered. Throughout the subsequent months, the facility repeatedly failed to promptly translate the wound provider’s treatment recommendations into active medical orders and to carry them out as written. Treatment changes ordered by the wound provider on several visits (including changes from Medihoney to Iodosorb, and later to Iodosorb plus calcium alginate, and then to Medihoney plus Xeroform) were implemented late, omitted, or altered by staff. For example, staff continued to use Iodosorb and calcium alginate for both the sacral and hip wounds after the provider had ordered Medihoney and Xeroform, and for a period treated the left hip with Medihoney and calcium alginate instead of Medihoney and Xeroform as ordered. During these periods of noncompliance with the wound care plan, the sacral wound increased in size and developed a high percentage of eschar, and the left hip wound increased in size. A second resident developed avoidable, facility-acquired bilateral heel pressure injuries. Contributing factors identified in the report included failure to float the heels prior to the development of the injuries, multiple missing weekly skin checks both before and after the heel wounds were discovered, and infrequent repositioning as evidenced by staff interview and observation. An air mattress, despite being a pressure-relieving intervention referenced in facility policy, was not provided until five days after the heel pressure injuries were identified. These actions and omissions show that the facility did not consistently implement its wound prevention program requirements for weekly skin checks, pressure redistribution surfaces, and regular turning and repositioning for this resident at risk for pressure injuries. Across both residents, the facility’s own policies required weekly skin checks documented in the EMR, prompt initiation of skin event assessments when abnormalities were noted, and implementation of individualized interventions in the care plan to prevent pressure injury development and promote healing. The report documents that these processes were not reliably followed: weekly skin checks were missed or undocumented, refusals were not consistently followed by re-approach and documentation, and wound care orders from the wound provider were not always entered accurately or in a timely manner. As a result, residents at risk for pressure injuries did not consistently receive the ordered and policy-required preventive care and wound treatments intended to prevent new pressure injuries and to promote healing of existing wounds.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Properly Investigate and Resolve Resident Grievance
Penalty
Summary
A deficiency occurred when the facility failed to properly address and resolve a grievance submitted on behalf of a resident who was dependent on staff for mobility due to multiple fractures and hemiplegia. The resident, who was cognitively intact, reported that a CNA refused to transfer them from a wheelchair to bed, citing the request was too close to shift change, resulting in the resident waiting an hour for assistance. The grievance documentation was incomplete, lacking a clear resolution and missing required signatures from the grievance official, DON, and NHA. Further investigation revealed that the social worker responsible for handling the grievance could not recall the details of the incident, was unable to locate additional information, and did not have statements from the CNA involved. There was no evidence that the CNA was interviewed or that the results of the grievance resolution were communicated to the resident or the NHA. The facility's policy required immediate attempts to resolve complaints, escalation if unresolved, and thorough investigation, including interviews with involved staff, none of which were documented in this case.
Medication Order Transcription Error Resulting in Missed Antiviral Doses
Penalty
Summary
A deficiency occurred when a resident admitted with cytomegaloviral disease (CMV) was prescribed intravenous ganciclovir, with instructions from the hospital to continue the medication twice daily and later changed to once daily by the Infectious Disease Clinic, with no specified stop date. The order was incorrectly transcribed by a registered nurse, who entered a stop date of 12/18/24 for the ganciclovir, despite the Infectious Disease Clinic's instructions that the medication should continue until the resident's follow-up appointment on 12/23/24. As a result, the resident did not receive five doses of the antiviral medication between 12/18/24 and 12/23/24. The error was discovered when the Infection Disease Clinic inquired about the early discontinuation of the medication. Facility documentation and interviews confirmed that the order transcription was not accurate, and the medication was stopped prematurely. The facility's investigation acknowledged the medication administration error and confirmed that the resident missed several doses due to the incorrect transcription of the physician's order.
Failure to Obtain Written Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain a written consent explaining the risks and benefits of the psychotropic medication Seroquel for a resident diagnosed with Delusional Disorder. The resident, who was prescribed Seroquel initially at 12.5 mg twice daily and later increased to three times daily, did not have a signed consent from the activated Health Care Power of Attorney (HCPOA). The facility was unable to provide documentation of the competency evaluation for the resident, and there were discrepancies in the activation dates of the HCPOA. Despite the resident's cognitive intactness as indicated by a Brief Interview for Mental Status (BIMS) score of 14, the facility did not ensure that the consent process was completed when the medication was first prescribed. The surveyor's review of the electronic health record confirmed the absence of a written consent for the antipsychotic medication, including the reason for its use, alternative treatments, and associated risks and benefits. The Nursing Home Administrator acknowledged the lack of documentation and the absence of a facility policy for obtaining consents for required medications. The Medical Records staff confirmed that verbal consent was obtained after the surveyor's inquiry, but acknowledged that the consent should have been obtained at the time of the initial prescription. The facility did not provide additional information to explain the oversight in obtaining the necessary consent.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report three allegations of abuse involving two residents and one resident-to-resident altercation to the State Survey Agency within the required timeframe. The first incident involved a resident who had a bruise of unknown origin, which was later diagnosed as cellulitis. Although the initial report was submitted, the Misconduct Incident Report was delayed by over a month due to a transition period involving the former Director of Nursing. The Nursing Home Administrator acknowledged the delay but provided no additional information to justify the late submission. The second incident involved a resident who alleged rape, with the initial report submitted late and the Misconduct Incident Report delayed. Additionally, the resident called the police to report an assault, but the facility failed to submit the required reports to the State Survey Agency. The Nursing Home Administrator was unaware of the police report and attributed the oversight to a transition period, admitting to a lack of timely reporting. The third incident involved a resident-to-resident altercation where one resident punched another. The initial report was submitted, but the Misconduct Incident Report was delayed by over a month. The Nursing Home Administrator was unaware of the delay until informed by the surveyor and acknowledged the concern. No further information was provided by the facility regarding the delay in reporting.
Inadequate Investigation of Abuse and Altercation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and resident-to-resident altercations, as evidenced by the incomplete Facility Reported Incidents (FRIs) and Misconduct Incident Reports. In the case of a resident, who alleged being raped and sustaining blunt force trauma, the facility did not collect all necessary staff and resident statements, nor did it perform a root cause analysis. Additionally, the facility did not report the incident to the State Survey Agency or complete a thorough investigation, despite the resident contacting the police about the alleged assault. In another incident involving two residents, one resident reportedly punched another in the face and cursed at them. The facility's investigation was inadequate as it lacked staff and resident statements, did not notify law enforcement, and failed to establish a pattern of behavior or agitation. The Misconduct Incident Report was only completed after the surveyor brought the issue to the facility's attention, indicating a lack of timely and comprehensive investigation. The facility's policy on reporting and investigating alleged incidents of abuse, neglect, exploitation, and mistreatment was not followed, as evidenced by the incomplete investigations and lack of corrective actions. The Nursing Home Administrator was unaware of some allegations and acknowledged the deficiencies in the investigation process, but no further information or corrective actions were provided at the time of the survey.
Failure to Implement PASARR Recommendations for Resident with Mental Health Needs
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination into the assessment, care planning, and transitions of care for a resident with mental health needs. The resident, identified as R58, was admitted with diagnoses including depression, anxiety, and other mental health disorders. Despite the PASARR Level 2 evaluation recommending specialized psychiatric rehabilitation services, the facility did not update the resident's care plan to include these services. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders receive appropriate care. However, the facility did not follow through with this policy for R58. The resident's care plan was not updated with person-centered interventions, and the interdisciplinary team (IDT) did not develop a plan to address the specialized psychiatric needs. Interviews with staff, including the social worker, psychologist, and nursing staff, revealed a lack of awareness and action regarding the specialized services required for R58. The deficiency was further highlighted by the facility's failure to submit a new Level 1 PASARR screen in a timely manner, which delayed the identification of the need for specialized services. The nursing home administrator and other staff members were not familiar with the requirements for specialized psychiatric rehabilitation services, and there was no documentation of these services being developed or implemented for R58. This lack of action and coordination resulted in the resident not receiving the necessary care to address their mental health needs.
Failure to Complete Timely PASARR for Resident
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident, identified as R58, who was admitted with a Level I PASARR indicating a stay of less than 30 days. However, R58 remained in the facility beyond this period without a resubmitted or updated PASARR, which should have triggered a Level II PASARR evaluation. This oversight was not addressed until 10/16/24, when a new Level I PASARR was submitted, revealing that R58 required specialized psychiatric rehabilitation services. R58 was admitted with diagnoses including Depression, Fracture of Left Femur, and other conditions. Despite having a Brief Interview for Mental Status (BIMS) score indicating cognitive intactness, R58 was diagnosed with several mental health disorders by a psychologist and psychiatrist, including Adjustment Disorder with Depressed Mood, Major Depressive Disorder, and Psychotic Disorder with Delusions. The facility's policy required a Level II PASARR evaluation within 40 days of admission if the resident stayed beyond the 30-day exemption, which was not completed in a timely manner. The breakdown in the PASARR process was attributed to a lack of communication and oversight, particularly concerning the activation of R58's Health Care Power of Attorney (HCPOA). The Admissions Director, Social Worker, and MDS Coordinator were involved in the process, but the necessary PASARR updates were delayed. The Nursing Home Administrator acknowledged the concern when it was brought to their attention by the surveyor, highlighting the facility's failure to adhere to its own policies and state regulations regarding PASARR screenings.
Failure to Update Resident Care Plan with Specialized Psychiatric Services
Penalty
Summary
The facility failed to update and implement a comprehensive person-centered care plan for a resident, identified as R58, to meet their psychosocial needs. The care plan did not incorporate the Level II PASARR recommendations, which indicated the need for specialized psychiatric rehabilitation services. Despite the determination that R58 required these services, the care plan remained unchanged, lacking person-centered interventions tailored to the resident's needs. R58 was admitted with multiple diagnoses, including depression and anxiety disorders, and was receiving psychotropic medications. The resident's care plan was not updated to reflect the need for specialized psychiatric rehabilitation services, which were recommended to address R58's mental illness. The facility's failure to revise the care plan meant that interventions were not aligned with the resident's current needs, as identified in the comprehensive assessment. The facility's policies require that care plans be reviewed and revised after each comprehensive and quarterly MDS assessment, as well as when a resident experiences a status change. However, R58's care plan had not been updated since the determination of the need for specialized services, and the facility did not provide documentation to clarify the activation date of the resident's Health Care Power of Attorney. The care plan focused on perceived negative behaviors without addressing the underlying causes or facilitating the resident's independence and emotional health.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, identified as R58, who was admitted with a left femur fracture and other medical conditions including depression, severe protein-calorie malnutrition, polyneuropathy, and anemia. Despite having a goal to discharge to a less restrictive environment, the facility did not provide consistent and active discharge planning since the resident's admission. The resident's care plan initially indicated a desire to return home, but was later revised to discharge to the most appropriate level of care without clear documentation of progress or actions taken to achieve this goal. The facility's policy required a comprehensive, person-centered care plan aligned with the resident's discharge goals, but this was not effectively implemented. The resident's Minimum Data Set (MDS) indicated cognitive intactness and a discharge plan to the community, yet no updated assessments or active discharge planning were documented. The social worker's notes revealed inconsistent communication and planning, with no evidence of referrals made to assess the resident's suitability for assisted living or other long-term care facilities, despite the resident's expressed desire to leave the facility. Interviews with the resident and facility staff highlighted the resident's distress and dissatisfaction with the current living situation, as well as a lack of documented efforts to facilitate a safe and appropriate discharge. The nursing home administrator acknowledged the concern but was unaware of the lack of active discharge planning. The social worker mentioned an outside agency's involvement in referrals, but there was no documentation to support this claim, indicating a significant gap in the discharge planning process.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that a resident, identified as R150, who is unable to carry out activities of daily living, received the necessary services to maintain good grooming. On a specific date, R150 was not provided with incontinence care every two hours as required by the care plan, resulting in the resident being observed with a saturated incontinence product. The facility's policy mandates that residents who are incontinent of bladder or bowel receive appropriate treatment to prevent infections and restore continence to the extent possible. R150 was admitted to the facility with multiple diagnoses, including diabetes mellitus, chronic kidney disease, and hemiplegia following a cerebral infarction. The resident's care plan, initiated and revised earlier in the year, included interventions such as cleaning the peri-area with each incontinence episode and checking for incontinence every two hours. Despite these interventions, the surveyor observed that R150's incontinence product was saturated with urine, and the resident had not been checked every two hours as required. During interviews, the CNA responsible for R150 admitted to not checking the resident every two hours on the day of the observation, acknowledging it was her fault. The LPN/UM confirmed that the expectation is for residents to be checked every two hours according to their care plan. The Nursing Home Administrator and Director of Nursing were informed of the deficiency, but no additional information was provided to explain why the necessary services were not provided to R150.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R58, to help achieve the highest possible quality of life. R58, who has a history of trauma, was not given an individualized plan of care to address this trauma. Despite a Level II PASARR screen indicating the need for specialized psychiatric rehabilitation services, the facility did not update R58's comprehensive care plan with person-centered interventions. The social worker did not assist R58 in identifying and preparing for alternate placement, and the facility lacked a policy for medically related social services. R58 was admitted with multiple diagnoses, including depression and anxiety, and was prescribed several psychotropic medications. However, the Medication Administration Record (MAR) was not accurately completed, failing to document behaviors or interventions related to R58's mental health needs. The facility's care plan for R58 was not person-centered and focused on perceived negative behaviors without addressing underlying causes or facilitating self-independence. The care plan had not been updated with new interventions since the determination of the need for specialized services. Interviews with staff and the resident revealed that R58 was experiencing significant distress, frequently refusing care, and expressing a desire to leave the facility. The social worker acknowledged the complexity of R58's case but did not complete a new trauma assessment after learning of past sexual trauma. The facility's failure to provide appropriate social services and update care plans contributed to R58's ongoing mental health crisis and dissatisfaction with the care received.
Failure to Prevent and Treat Pressure Injury
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent the development of pressure injuries and to promote healing for a resident identified as R62. R62 developed a pressure injury on the right buttock, which was not comprehensively assessed, and there was a delay in physician notification for treatment. The pressure injury worsened during this period, and by the time the wound physician assessed it, the injury was unstageable and required debridement. The facility did not conduct a comprehensive assessment of R62's risk factors, including severe protein malnutrition and decreased mobility, which contributed to the development of the pressure injury. R62 was admitted with severe protein malnutrition, dysphasia, and severe dementia, and was at risk for pressure injuries. Despite these risk factors, the facility did not adjust the care plan to address the resident's nutritional needs or implement preventative measures for pressure injuries. The resident experienced significant weight loss, which was not addressed in the care plan, and there was no comprehensive assessment of the resident's nutritional needs to promote wound healing. The facility's failure to promptly assess and treat the pressure injury, along with inadequate nutritional interventions, contributed to the decline in R62's condition. The facility's policy required a comprehensive assessment of residents to prevent pressure injuries, but this was not followed in R62's case. The interdisciplinary team met to discuss the new pressure injury but classified it as unavoidable without making necessary changes to the care plan. The facility did not notify the physician of the pressure injury's decline, and there were no changes in treatment until the wound physician's assessment. The lack of timely intervention and comprehensive assessment led to the finding of immediate jeopardy, indicating a serious risk of harm to the resident.
Failure to Maintain Nutritional Status Leads to Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R62, maintained acceptable parameters of nutritional status, leading to severe weight loss and the development of a stage 4 pressure injury. R62 was admitted with severe protein malnutrition, dysphasia, and severe dementia, requiring assistance with eating. Despite these conditions, the facility did not conduct comprehensive nutritional assessments or develop an individualized plan of care. The resident's nutritional assessments did not include accurate weights or individualized interventions, and there was a lack of documentation regarding vitamins, mineral supplements, or high-calorie food options. R62 experienced significant weight loss, dropping from 130 lbs to 69.2 lbs, a 46.7% decrease, which contributed to the development of a stage 4 pressure injury and the resident being placed on hospice care. The facility's records showed inconsistencies in weight documentation, and the resident's family expressed disbelief in the recorded weights. Despite the resident's poor oral intake and the presence of dementia, the facility did not revise the plan of care to address these issues adequately. The resident's speech therapy recommendations were not implemented in the care plan, and there was no comprehensive assessment to identify causative factors for the severe weight loss. The facility's failure to provide adequate nutrition and conduct comprehensive assessments resulted in a finding of immediate jeopardy. The resident's nutritional assessments lacked a personalized approach, and there were no changes in the plan of care until mid-July, despite the resident's declining condition. The facility did not ensure that the resident's nutritional status was maintained within acceptable parameters, leading to severe weight loss and further health complications.
Inaccurate COVID-19 Reporting and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure accurate data collection and reporting during a COVID-19 outbreak, which led to deficiencies in their infection prevention and control program. The outbreak was initially identified when two staff members tested positive, followed by two residents. However, the infection line list did not accurately reflect all cases, as two residents who tested positive were not included. Additionally, the monthly infection rates were inaccurate, with residents being prescribed antibiotics without documented signs, symptoms, or diagnoses. The Infection Preventionist (IP) admitted to not correlating certain cases with the outbreak and failing to update the line list accordingly. Furthermore, the facility did not post visual alerts or signs to notify staff and visitors of the ongoing COVID-19 outbreak, as required by their own policies. This lack of communication could have contributed to the spread of the virus within the facility. The IP acknowledged the absence of signage and attributed it to oversight, as well as a lack of understanding of the correlation between the outbreak and the positive cases. In addition to the issues with infection reporting and communication, the facility was observed to have deficiencies in hand hygiene practices among CNAs during meal service. CNAs were seen not using hand hygiene appropriately, such as changing gloves without washing hands or using alcohol-based hand rub. The Director of Nursing (DON) confirmed the expectation for proper hand hygiene, but the observed practices did not align with these expectations. This failure in hand hygiene could potentially affect all residents in the facility.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. One resident, who was assessed as an independent smoker, did not have a care plan in place to address smoking safety needs and interventions. Despite being identified as a smoking resident, the facility did not document a person-centered comprehensive care plan for this resident's smoking habits. Another resident with chronic nosebleeds and diabetes did not have care plans addressing these conditions. The resident's medical records indicated a history of nosebleeds and a prescription for Afrin Nasal Spray, but no care plan was created to manage these nosebleeds or the resident's diabetes. The facility's failure to document care plans for these conditions was noted during interviews with the Unit Manager and the Director of Nursing, who acknowledged that such conditions should be care planned. Additional deficiencies were identified for residents using antipsychotic and antianxiety medications, specialized communication needs, and anticoagulant medication. One resident did not have a care plan for the use of antipsychotic and antianxiety medications, including non-pharmacological interventions and side effects monitoring. Another resident with communication deficits did not have a comprehensive communication care plan, despite being dependent on pen and paper for communication. Furthermore, a resident on anticoagulant medication and using a condom catheter did not have care plans addressing the use and monitoring of these interventions. These omissions were confirmed during interviews with facility staff and highlighted during the surveyor's exit meetings with the Nursing Home Administrator and Director of Nursing.
Expired Medications Found in Facility's Storage Rooms
Penalty
Summary
The facility failed to ensure that medication storage rooms were free of expired medications, affecting two medication storage rooms. During an inspection, a surveyor observed expired medications, including 0.9% sodium chloride irrigation bottles and Systane lubricant eye drops, in the 2900 unit medication storage room. Additionally, expired tear eye drop advance bottles were found in both the 2900 and 2700 unit medication storage rooms. The surveyor questioned the Medication Technician and the Director of Nursing (DON) about the responsibility for checking expired medications, and both indicated that it was a shared responsibility among all staff, particularly the night shift. Furthermore, the surveyor found a bottle of Lantus insulin for a resident in the 2700 unit medication storage room that was opened and not dated, along with another expired bottle of Lantus insulin. The DON confirmed that the protocol was to date insulin when opened and to consider it expired after 28 days, advising staff to verify with the pharmacy if unsure. Despite these protocols, the facility did not ensure that the medication storage rooms were free of expired medications, potentially affecting residents who may have eye drops ordered.
Deficiency in Monitoring and Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper monitoring and dose reductions for residents on psychotropic medications, as observed in four out of six resident medication reviews. Specifically, residents receiving antipsychotic medications did not have Abnormal Involuntary Movement Scale (AIMS) assessments completed to monitor for side effects. For instance, a resident with schizoaffective disorder and dementia was on routine antipsychotic medication, but there was no documentation of an AIMS assessment until after the surveyor's request. Similarly, another resident with Alzheimer's dementia and agitation was on Seroquel, yet no AIMS assessment was completed due to a failure in the facility's electronic system to trigger the assessment. Additionally, the facility did not attempt gradual dose reductions for certain residents on psychotropic medications. One resident receiving Cymbalta and Sertraline for depression had no documented evidence of attempted dose reductions, and the Director of Nursing acknowledged the lack of documentation. Another resident on Seroquel for nightmares also did not have a gradual dose reduction or psychiatric consult documented, as confirmed by the Infection Preventionist. The facility's policy on the use of psychotropic medications requires gradual dose reductions and AIMS assessments, but these were not consistently followed. The Nursing Home Administrator and Director of Nursing were informed of these deficiencies during the survey, but no additional information was provided to justify the lack of monitoring and dose reductions for the affected residents.
Failure to Report Abuse and Injury Incidents
Penalty
Summary
The facility failed to report two out of three allegations of abuse or neglect to the State Survey Agency within the required timeframe. Specifically, an accusation of abuse involving a resident, identified as R77, was not reported to the Nursing Home Administrator (NHA) within the required timeframe. The incident was known to the facility on one day but was not communicated to the NHA until the following day. The delay was attributed to a supervisor's belief that the incident was a result of a personal disagreement between two Certified Nursing Assistants, with no signs of abuse observed. Additionally, the facility did not report a resident-to-resident altercation involving R77 to the State Survey Agency. The altercation occurred when a CNA attempted to escort R77 to their room, resulting in R77 biting another resident who tried to assist. The incident was reviewed by the facility's Interdisciplinary Team (IDT), but it was determined that it did not meet the guidelines for reporting to the Department of Health Services. The Director of Nursing (DON) and the NHA acknowledged that the incident was not reported. Furthermore, the facility did not investigate or report an injury of unknown origin involving another resident, identified as R5, who returned from hospitalization with a femur fracture. The facility's NHA indicated that the fracture was idiopathic due to age and did not occur within the facility, thus no investigation or report was made to the State Agency. However, the NHA acknowledged the requirement to report injuries of unknown origin, and the facility failed to comply with this requirement.
Failure to Investigate Abuse Allegations and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and injuries of unknown origin for two residents, R5 and R77. R5 returned to the facility from a hospitalization with a femur fracture, but the facility did not investigate the cause of this injury. The Nursing Home Administrator (NHA) indicated that the fracture was idiopathic due to age and did not occur within the facility, thus no investigation was conducted. However, the surveyor noted that the facility is required to investigate injuries of unknown origin, and the NHA acknowledged this requirement but did not provide any additional information or documentation of an investigation. For R77, an accusation of abuse was made, but the investigation was not thorough. The NHA interviewed the accused Certified Nursing Assistant (CNA) and the supervisor on duty but allowed the CNA to continue working with residents until the end of their shift and the start of a new shift the next day. There was a delay in preventing further potential abuse, and the NHA provided minimal education to the supervisor involved, with no evidence of broader staff education or resident interviews. The surveyor noted the lack of thorough investigation and documentation, as the provided resident interview sheet lacked dates, times, and signatures. Additionally, a resident-to-resident altercation involving R77 was not properly investigated or reported. The incident was documented in progress notes, but the required Department of Health Services Form was not submitted to the State Survey Agency. During the exit meeting, the NHA and Director of Nursing acknowledged the failure to report the incident and did not provide any investigation records. This lack of thorough investigation and reporting for both residents highlights deficiencies in the facility's handling of abuse allegations and injuries of unknown origin.
Failure to Provide Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notifications of transfer to the hospital for three residents, as required by their policy. Resident R5 was transferred to the hospital multiple times due to changes in condition, but neither R5 nor their representative received written notifications for these transfers. Additionally, the State Ombudsman was not informed. The Nursing Home Administrator (NHA) acknowledged that the nursing staff, who were responsible for providing these notifications, had not been completing them. Similarly, Resident R34 was transferred to the hospital for sepsis and transverse colitis, but there was no evidence that a transfer notice was provided to R34 or their representative. Resident R32 also experienced a change in condition that necessitated a hospital transfer, yet no transfer notice was documented. The NHA confirmed that the nursing staff had not completed the required transfer notices for these residents, and no additional information was provided to explain the oversight.
Inaccurate MDS Documentation for Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the behaviors of a resident, identified as R77, during the assessment period. The Quarterly MDS for R77, with an assessment reference date of 6/19/24, incorrectly documented that the resident did not exhibit certain behaviors, such as physical behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, rejection of evaluation or care, and wandering. However, a review of progress notes during the look-back period indicated that these behaviors did occur and were treated with PRN medication as necessary. R77 was admitted to the facility with diagnoses including degenerative disease of the nervous system, unspecified dementia with agitation and anxiety, generalized anxiety disorder, major depressive disorder, and wandering. The progress notes documented multiple instances of behaviors such as wandering, agitation, and resistiveness, which were managed with PRN medications like Lorazepam. Despite these documented behaviors, the MDS inaccurately reflected that these behaviors were not exhibited by R77. Interviews with facility staff revealed that the MDS Coordinator did not complete R77's quarterly MDS and directed the surveyor to speak with the social worker, who was unavailable. The Nursing Home Administrator acknowledged the discrepancies in the MDS and indicated that the social worker did not complete the assessment correctly, suggesting a need for training on MDS completion. No further explanation was provided for the inaccuracies in the MDS documentation.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to update the comprehensive person-centered care plans for three residents, which led to deficiencies in meeting their medical, nursing, and psychosocial needs as identified in their comprehensive assessments. Resident R64's care plan was not updated after the removal of a Foley catheter, despite observations and interviews confirming the absence of the catheter. The care plan continued to document the presence of the catheter and related interventions, indicating a lack of timely revision by the facility staff. Resident R49's care plan was not updated to address the use of a condom catheter, and Resident R29's care plan was not revised to include the use of a Tenashape compression sleeve ordered for edema management. The facility's policy requires care plans to be reviewed and revised after each comprehensive and quarterly MDS assessment and upon any status change, but these updates were not made, leading to discrepancies between the residents' current needs and their documented care plans. Interviews with facility staff, including the Unit Manager and the Director of Nursing, revealed an acknowledgment of the oversight in updating the care plans. The facility's policy outlines the responsibility of designated staff, such as the MDS Coordinator and Unit Managers, to ensure care plans reflect current resident needs and communicate changes to all involved staff. However, these procedures were not followed, resulting in the identified deficiencies.
Failure to Address Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to act upon pharmacist recommendations for two residents, R62 and R77, during their monthly drug regimen reviews. For R62, who was admitted with Alzheimer's dementia, pharmacy reviews conducted in June and July 2024 noted the absence of an appropriate diagnosis for the use of the antipsychotic medication Seroquel. Despite these findings, there was no documentation in the medical record indicating that the physician acknowledged or acted upon the pharmacist's recommendations. The Nursing Home Administrator provided the surveyor with the pharmacy review notes, but no explanation was given for the lack of physician response. Similarly, for R77, who was admitted with multiple diagnoses including unspecified dementia with agitation and anxiety, the pharmacy review notes from April to August 2024 consistently highlighted the absence of an allowable diagnosis for the use of Seroquel. Despite repeated recommendations from the pharmacist, these concerns were not addressed, and there was no follow-up action taken by the facility. The Director of Nursing confirmed that the recommendations were not acted upon, and no additional information was provided to explain the oversight.
Failure to Administer Anticoagulant Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Plavix, an anticoagulant medication. The resident, who has a history of type 2 diabetes mellitus, atherosclerotic heart disease, and essential hypertension, did not receive six doses of Plavix over a period of approximately two weeks. The facility's policy requires immediate action when medications are unavailable, including notifying the physician and obtaining alternative treatment orders. However, the medication was not administered on multiple occasions due to reasons such as 'on order' and 'await pharmacy delivery,' despite the facility having an Omnicell system for accessing medications. Interviews with facility staff, including a Certified Medication Assistant (CMA), Licensed Practical Nurse (LPN), and the Director of Nursing (DON), revealed inconsistencies in following the established protocol for obtaining medications from the Omnicell. The CMA indicated they would call the pharmacy and seek assistance from a nurse, while the LPN and DON confirmed that medications should be retrieved from the Omnicell. The DON acknowledged that Plavix was available in the Omnicell and indicated a need to investigate why the medication was not administered, suggesting potential training issues with staff or agency workers. The deficiency was communicated to the Nursing Home Administrator and the DON, but no further information was provided regarding the failure to administer the medication as prescribed.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that one of five Certified Nursing Assistants (CNAs) reviewed received the required 12 hours of continuing competence training. This deficiency potentially affects 90 residents who could receive care from the CNA. CNA-M, who was hired on October 31, 2022, only received 4.5 hours of continuing competence training. During the survey on September 10, 2024, the surveyor reviewed CNA-M's training record and confirmed the shortfall in training hours. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the training department is responsible for tracking and ensuring CNAs complete their required training hours. However, CNA-M was overlooked, and no additional information was provided to explain why the facility did not ensure the completion of the required training hours.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three residents. One resident, identified as having a deep tissue injury, did not receive timely lab tests, and the prescribed antibiotic was not administered for the full duration. The facility also failed to implement a treatment plan for a Stage 1 sacrum pressure injury, which later progressed to Stage 2. The care plan for this resident was not updated until 14 days after the pressure injury was identified. Another resident, who was at risk for pressure injuries, developed multiple facility-acquired pressure injuries, including an unstageable right heel pressure injury that became infected, leading to hospitalization and an above-the-knee amputation. The facility did not update the resident's care plan or implement necessary interventions to prevent the deterioration of the pressure injuries. A third resident developed a Stage 2 pressure injury that was not comprehensively assessed until it had declined to an unstageable wound. The facility did not revise the resident's care plan or involve a dietician when the new pressure injury developed. The resident was observed not receiving incontinence care or repositioning as care planned. The facility's policy and procedure for pressure ulcer care did not include evaluation of the stage or description of the wound bed, contributing to the deficiencies observed.
Failure to Implement Fall Prevention Care Plans
Penalty
Summary
The facility failed to implement care plans for residents at high risk for falls, leading to significant injuries. One resident, admitted with a fractured left hip, was assessed as high risk for falls but did not have a care plan addressing this risk. Despite multiple documented instances of restlessness and attempts to get out of bed unassisted, no fall prevention interventions were implemented. This resident eventually fell and sustained a right hip fracture, requiring hospitalization. The facility's records did not show any RN assessment after the fall, and the care plan was never updated to include fall prevention measures. Another resident, also at high risk for falls, experienced an unwitnessed fall resulting in a right intertrochanteric fracture. The investigation into this fall was inadequate, lacking a head-to-toe assessment, staff statements, and a root cause analysis. Despite the resident's high fall risk, no new interventions were implemented following the fall. Observations during the survey revealed that the resident's call light was not within reach, and the resident was not in a low bed, contrary to the facility's fall prevention protocols. The facility's policies require comprehensive assessments and care plans for residents at risk of falls, but these were not followed. The lack of appropriate care plans and post-fall assessments contributed to the residents' injuries. The facility's failure to adhere to its fall prevention policies and procedures resulted in significant deficiencies in the care provided to these residents.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R3, in a timely manner to the State Survey Agency and local law enforcement. On April 17, 2024, an allegation was made that a certified nursing assistant (CNA) choked R3. This incident was not reported to the state survey agency within the required 2-hour timeframe for serious bodily injury, nor was local law enforcement notified immediately. The facility's policy requires that all alleged incidents of abuse, neglect, exploitation, and mistreatment be reported promptly, but this protocol was not followed in this case. R3, who has a medical history including Alzheimer's Disease, Dementia with Psychotic Disturbance, and other conditions, was reportedly involved in an incident where another resident, R4, overheard verbal and physical abuse. R4 reported hearing R3 choking and later yelling about being choked. Despite R4's immediate attempt to report the incident by using the call light, it was not answered until several hours later by the next shift. The facility's report to the State Survey Agency was submitted late, and it lacked documentation of the time the facility was made aware of the incident or when the administrator was notified. The social worker responsible for submitting the Facility Reported Incident (FRI) could not recall why the report was delayed or why law enforcement was not notified. The Nursing Home Administrator acknowledged the concern but could not provide additional information. The failure to report the incident within the required timeframes and to notify law enforcement constitutes a deficiency in the facility's compliance with reporting and investigation guidelines.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving two residents, R3 and R4. For R3, an incident was reported where R3 was allegedly choked by a CNA. The investigation was incomplete as it lacked statements from all potential witnesses, including other residents and staff members. Additionally, there was no documentation of a head-to-toe physical assessment of R3, and local law enforcement was not notified. The facility's report did not include a root cause analysis or a comprehensive collection of evidence, such as statements from the accused CNA and the nurse on duty. R4 reported overhearing an altercation involving R3 and a CNA, including sounds of physical abuse and verbal threats. Despite R4's detailed account, the facility's investigation did not capture all relevant staff and resident statements. The investigation was further compromised by the absence of a BIMS and PHQ-9 assessment for R3, which could have provided insight into R3's mental status and ability to recall the incident. The social worker responsible for the investigation could not provide explanations for these omissions. In a separate incident involving R4, the facility again failed to conduct a thorough investigation. R4 reported verbal abuse and neglect by a CNA, but the facility's investigation lacked follow-up with several staff members who did not respond to initial contact attempts. There were also no resident statements collected to assess if there were prior concerns with the CNA involved. The facility's documentation did not demonstrate a comprehensive effort to gather all necessary information to address the allegations adequately.
Failure to Ensure Timely Follow-Up Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely follow-up care as per hospital discharge instructions and professional standards of practice. The resident, who was admitted with multiple diagnoses including Alzheimer's Disease and a right intertrochanteric femur fracture, was instructed to have an orthopedic consult within six weeks post-discharge. However, the consult did not occur until nearly three months later. Additionally, the resident was supposed to return for a repeat x-ray one month after the initial consult, but there is no documentation that this appointment was attended. Furthermore, a subsequent orthopedic appointment was scheduled but not attended, with no documentation explaining the absence. The facility lacked a policy and procedure for managing resident appointments, which contributed to the oversight. The Health Information Manager acknowledged discrepancies in the scheduling and follow-up of the resident's appointments, citing issues with appointment availability and escort provision. Despite a training session conducted in March 2024 to address timely appointment scheduling, the resident's care was not aligned with the comprehensive person-centered care plan or the resident's choices, as evidenced by the missed and delayed appointments.
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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