Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Wauwatosa, Wisconsin.
- Location
- 7500 W North Ave, Wauwatosa, Wisconsin 53213
- CMS Provider Number
- 525545
- Inspections on file
- 19
- Latest survey
- June 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lutheran Home during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide complete transfer and bed-hold notices during resident hospitalizations, omitting required contact information for the State Long-Term Care Ombudsman and appeal agencies, and failing to notify the Ombudsman as required. Staff interviews confirmed a lack of awareness and absence of a policy addressing these requirements.
Staff did not follow established recipes or measurement protocols when preparing pureed foods, resulting in unmeasured and inappropriate ingredients being used, such as water instead of broth and omission of margarine. This practice affected multiple residents on pureed diets, as food was not prepared in a manner that conserved nutritional value, flavor, or appearance.
Surveyors found that food stored in a unit refrigerator was not properly labeled or dated, and the refrigerator temperature was consistently above the recommended safe range. Despite facility policy requiring labeling, dating, and daily monitoring of food and refrigerator temperatures, these procedures were not followed, as evidenced by unlabeled food items and temperature logs showing persistent out-of-range readings.
Surveyors found that staff, including nurses, wound care providers, and CNAs, repeatedly failed to wear required PPE such as gowns and gloves during high-contact care activities like wound care, incontinence care, catheter care, and tube feeding for residents with wounds, catheters, and feeding tubes. These actions were observed despite facility policies and care plans mandating Enhanced Barrier Precautions, and in some cases, necessary signage was missing from resident rooms. Staff and leadership interviews confirmed these lapses were not in line with facility expectations.
Two residents did not receive required ADL care, including scheduled showers and nail care, as outlined in their care plans and facility policy. One resident missed multiple showers due to staff absence and lack of communication, while another did not receive timely podiatry services for nail trimming, resulting in unmet care preferences.
Two residents with pressure injuries did not receive comprehensive wound assessments as required by facility policy. One developed a pressure injury in the facility that was not fully assessed at onset, and another was readmitted with a pressure injury that was not comprehensively evaluated for several days. Nursing staff and the DON confirmed the lack of complete assessments, resulting in deficiencies in treatment and care planning.
Surveyors found that insulin and eye drop medications in two medication rooms and one medication cart were either expired or not dated when opened, contrary to facility policy and professional standards. An LPN confirmed that these medications should have been dated and discarded once expired. The facility was notified of these labeling and storage deficiencies.
A resident with chronic kidney disease and dysuria, who was frequently incontinent of bladder, did not have a comprehensive care plan for urinary incontinence. The care plan only included basic toileting assistance and use of a brief, without addressing the reasons for incontinence, type, goals, or additional interventions, and did not reference the resident's renal disease or dysuria. Facility policy required more detailed planning, but this was not present.
Two residents with chronic pain conditions did not receive comprehensive pain management services, as required by professional standards. One resident experienced frequent, severe pain and was not offered non-pharmacological interventions, with no pain care plan or thorough assessment in place. Another resident's care plan lacked specific pain management goals and did not document all prescribed pain medications or complete pain assessments. The DON confirmed the absence of comprehensive pain care plans and assessments for both residents.
Surveyors found that several residents with serious mental illness, as identified by PASRR screenings and medical diagnoses, were not accurately documented in the MDS assessments. Staff acknowledged that the assessments were coded incorrectly, resulting in the omission of serious mental illness status in the required documentation.
A resident sustained a bruise near their eye due to improper use of a Hoyer lift with support bars, which staff were not trained to use. The lift's side bars do not lock in an upward position, and during a transfer, a bar fell and hit the resident. The facility failed to provide training or implement preventive measures following the incident.
The facility failed to ensure food safety and proper storage, affecting all residents. Staff did not test the sanitizing solution correctly or log results, and the unit refrigerator on 2E had unlabeled, undated food and was unclean, with no current temperature log.
The facility failed to ensure food was prepared to conserve nutritive value for 8 residents on a pureed diet. The Cooks Helper did not follow a recipe or the IDDSI framework, using unmeasured amounts of water and thickening agent, and did not use a liquid with nutritious value.
The facility failed to ensure proper catheter care and privacy for three residents, leading to multiple observations of uncovered catheter drainage systems and bags placed directly on the floor. Despite care plans requiring protective measures, the facility did not provide privacy bags or barriers, compromising the residents' dignity and increasing the risk of infection.
A facility failed to provide proper pharmaceutical services when an LPN did not follow safety protocols while administering insulin to a resident with Alzheimer's, Chronic Kidney Disease, and Type 2 Diabetes. The LPN did not recap the needle, waved it in the air, and donned gloves while holding the uncapped needle, leading to safety concerns.
A resident with multiple diagnoses was prescribed an antibiotic for a respiratory infection before obtaining a respiratory panel, which later confirmed a viral infection. Despite the results, the antibiotic treatment continued without documented follow-up with the prescribing physician, highlighting a deficiency in the facility's management of the resident's drug regimen.
The facility failed to maintain a medication error rate below 5%. Errors included administering expired Novolin insulin to one resident and Aspirin with an illegible expiration date to another. The facility's policies on medication disposal and labeling were not followed.
The facility failed to ensure proper storage and labeling of medications, with surveyors finding undated, opened eye drops, unlabeled medications, expired insulin, and improper storage practices. Additionally, a salad was found in the medication fridge, and the refrigerator temperature was above the acceptable range.
Failure to Provide Required Transfer and Bed-Hold Notices with Ombudsman and Appeal Information
Penalty
Summary
Surveyors identified that the facility failed to provide the required documentation and notifications during resident transfers to the hospital. Specifically, transfer and bed-hold notices for multiple residents did not include the email address for the state agency, the facility, or the contact information for the Office of the State Long-Term Care Ombudsman. Additionally, the notices lacked information on how to contact the Ombudsman, and the required notifications were not sent to a representative of the Ombudsman office. This deficiency was observed in the records of four out of five residents reviewed for hospitalizations. Interviews with facility staff, including the Nursing Home Administrator and Social Worker, revealed a lack of awareness regarding the requirement to include Ombudsman contact information and to notify the Ombudsman during transfers, not just discharges. The facility also did not have a specific policy or procedure addressing transfer notice requirements. The documentation reviewed consistently omitted the necessary appeal contact emails and Ombudsman details, and staff confirmed that these notifications were not being completed as required.
Failure to Follow Pureed Food Preparation Protocols
Penalty
Summary
The facility failed to ensure that pureed foods were prepared according to established recipes and procedures designed to conserve nutritional value, flavor, and appearance. During observation, a cook prepared pureed greens without accurately measuring the amount of greens, thickener, or liquid added. The cook used a strainer with no visible measurement markings to estimate the quantity of greens and added an unmeasured amount of thickener and water, contrary to the recipe instructions. The recipe specifically directed that margarine be added and that any liquid used for thinning should not be water, but rather a suitable alternative such as broth. However, margarine was omitted, and water was used for thinning, both in unmeasured amounts. The cook reported that he was trained to add water as needed to achieve the desired consistency and did not follow a specific measured amount for either thickener or liquid. The recipe required gradual addition of thickener and liquid, but the cook added both all at once. The Dining Director confirmed that the recipe in use did not specify the amount of thickener and acknowledged that the correct liquid for thinning should be broth or a similar alternative, not water. The strainer used to measure the greens was also found to lack any measurement indicators, making it impossible to confirm the quantity used. These deviations from the recipe and facility policy resulted in pureed food being prepared in a manner that did not ensure consistency, nutritional value, or palatability for residents on a pureed diet. The deficiency had the potential to affect eight residents who required pureed diets, as the food preparation did not adhere to the standards set forth by the facility's policies and the registered dietician's or physician's orders.
Failure to Properly Store and Label Resident Food and Maintain Safe Refrigerator Temperatures
Penalty
Summary
Surveyors identified that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of three resident unit refrigerators. Specifically, food items stored in the refrigerator were not labeled with resident names or dates, and some items were not dated at all. The facility's own policy required all perishable food brought in by family or visitors to be labeled with the resident's name, date received/opened, and discard date, and for nursing staff to monitor and document this daily. However, observations revealed unlabeled and undated food items, including Styrofoam containers and a plate with only a resident's name but no date. Additionally, the refrigerator temperature was consistently above the recommended safe range for food storage. The temperature gauge inside the refrigerator was observed at 68 degrees Fahrenheit, and a review of the temperature log from January through June showed all recorded temperatures were above 41 degrees Fahrenheit, with most readings between 48-52 degrees. The facility's policy and posted instructions required refrigerator temperatures to be maintained between 37-41 degrees Fahrenheit. Despite this, the temperature log was regularly initialed as if the refrigerator was within range, and no corrective action was documented in response to the out-of-range temperatures.
Failure to Follow Enhanced Barrier Precautions and PPE Use During High-Contact Care
Penalty
Summary
Surveyors observed multiple instances where staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact resident care activities. In several cases, staff—including registered nurses, wound care physicians, nurse managers, wound technicians, certified nursing assistants, and advanced practice nurse practitioners—did not wear required personal protective equipment (PPE) such as gowns and gloves while performing wound care, incontinence care, catheter care, and tube feeding care. These lapses were directly observed during wound treatments for residents with pressure injuries, indwelling catheters, and feeding tubes, despite clear signage and care plans indicating the need for EBP. Specific incidents included a registered nurse performing wound care on a resident with multiple pressure injuries and a Foley catheter without donning a gown, as well as a wound care physician conducting wound debridement with only one glove and using an ungloved hand. Certified nursing assistants were seen providing incontinence and peri care without changing gloves or performing hand hygiene between tasks, and in some cases, did not wear gowns as required. Additionally, a licensed practical nurse was observed flushing a resident's feeding tube without wearing a gown, and there was no EBP sign on the resident's door, contrary to facility policy. Interviews with staff and leadership confirmed that the expectation was for gowns and gloves to be worn during high-contact care for residents on EBP, and that signage should be present to alert staff to these requirements. Staff acknowledged lapses as oversights or due to missing signage, and leadership reiterated the policy requirements. The surveyors documented these deficiencies as failures to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases.
Failure to Provide Scheduled Showers and Nail Care per Care Plan
Penalty
Summary
Two residents did not receive necessary assistance with activities of daily living (ADLs) as required by their care plans and facility policy. One resident, with a history of a rare neuromuscular disorder, bladder dysfunction, pain, cellulitis, and urinary retention, was dependent on staff for bathing and had a physician order for weekly showers. On the scheduled shower day, the assigned shower aide was absent due to illness, and the resident was not provided with a shower or an alternative bathing method. The resident was not informed about the missed shower and expressed concern, noting that a shower had also been missed the previous week. Documentation confirmed that the last shower provided was nearly two weeks prior, despite the resident's dependence on staff and stated preference for showers. Another resident, diagnosed with diabetes mellitus with neuropathy and requiring assistance with personal care, did not receive regular nail care as outlined in the care plan and facility policy. The care plan specified referral to podiatry for nail trimming, but the resident's toenails were observed to be long, and the resident expressed a preference for short nails. Staff interviews revealed that the resident was not on the current podiatry list, and there was a lack of communication regarding the need for podiatry services. The facility required consent from the resident's power of attorney for podiatry visits, which had not been obtained in a timely manner, resulting in the resident not receiving necessary nail care. The facility's policy stated that all residents should receive weekly showers or baths and regular nail care as needed. However, both residents did not receive these services according to their care plans and preferences. Staff interviews and documentation review confirmed that the facility failed to provide the required ADL care, and no additional information was provided to explain the lack of services.
Failure to Complete Comprehensive Pressure Ulcer Assessments
Penalty
Summary
The facility failed to ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice. For one resident with dementia, CHF, and diabetes, a pressure injury developed while in the facility. Although staff documented the presence of an open area and initiated wound care, a comprehensive assessment of the wound—including staging, wound bed, peri-wound, and other required characteristics—was not completed at the time of discovery. The care plan included interventions such as pressure-reducing devices and repositioning, but the initial assessment did not meet the facility's policy requirements for a comprehensive evaluation. Another resident, admitted with a history of cancer and at risk for pressure injuries, developed a pressure injury to the sacrum that was appropriately assessed prior to a hospital transfer. Upon readmission, the resident's pressure injury was not comprehensively assessed for three days, and the plan of care did not reflect the presence of an actual pressure injury or include comprehensive interventions. Documentation provided after readmission only included wound measurements and lacked detailed assessment of wound characteristics as required by facility policy. Interviews with nursing staff and the DON confirmed that comprehensive wound assessments were not completed as required for both residents. The facility's own policy mandates a thorough evaluation of wounds, including size, depth, location, stage, wound base, peri-wound, drainage, pain, and wound edges, but this was not followed. As a result, the facility did not ensure that residents with pressure injuries received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility were not consistently labeled in accordance with accepted professional principles. Specifically, in two medication rooms and one medication cart, insulin vials and pens, as well as eye drop solutions, were found either expired or not dated when opened. Facility policy requires that multi-dose medications be dated when opened and that expired or contaminated medications be removed and disposed of properly. However, surveyors found multiple instances where insulin and eye drops were open and in use without being dated, and some insulin was found to be expired but still stored in the medication rooms and cart. During the observations, surveyors identified specific medications, such as Lispro insulin, Novolin 70/30 insulin, Lantus insulin pens, Brimonidine eye drops, and Prednisolone eye drops, that were either expired or lacked an opening date. An LPN confirmed that all these medications should have been dated when opened and discarded once expired. The facility was notified of these concerns during the exit meeting, and no additional information was provided.
Lack of Comprehensive Care Plan for Urinary Incontinence
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease and dysuria, who was frequently incontinent of bladder, did not have a comprehensive care plan addressing her urinary incontinence. The resident's Minimum Data Set (MDS) and Care Area Assessment (CAA) indicated frequent incontinence and a need for assistance with toileting, including transfers and hygiene. Despite these documented needs, the care plan only included an intervention to offer toileting every 2-3 hours and as needed, and to use a brief, without specifying the reasons for incontinence, the type of incontinence, specific goals, or additional interventions. There was also no documentation in the care plan regarding the resident's renal disease or dysuria. Review of the CNA care card showed similar limited instructions, and interviews with the Director of Nursing confirmed that no further interventions or comprehensive planning were in place for the resident's bowel and bladder incontinence. The facility's policy required care plans to include goals and considerations of risks affecting the resident's health, but these elements were missing in this case. No additional information was provided by facility leadership to explain the lack of a comprehensive care plan for the resident's urinary incontinence.
Failure to Provide Comprehensive Pain Management and Assessment
Penalty
Summary
The facility failed to provide safe and appropriate pain management services consistent with professional standards of practice for two out of five residents reviewed. For one resident with a history of fibromyalgia and chronic pain, documentation showed frequent and severe pain, with pain scores ranging from 5 to 10 prior to administration of as-needed opioid analgesics. Despite this, there was no comprehensive pain care plan or thorough pain assessment in the resident's records, and the care plan lacked any interventions for pain. The resident reported that pain medication was only effective for a short period and that non-pharmacological interventions were never offered, even though the resident expressed willingness to try them. Medication administration records indicated repeated use of as-needed pain medication, with several instances where pain was not relieved and no follow-up actions were documented. Another resident with diagnoses including unspecified pain, low back pain, and dysuria was also not provided with a comprehensive pain management plan. Although the resident received scheduled pain medications and reported that these were effective, the care plan only referenced pain management under a self-care deficit section and did not include specific problems or goals related to pain. Non-pharmacological interventions were minimally documented, and the care plan failed to mention all prescribed pain medications. Pain assessments were incomplete, lacking details such as pain location, acceptable pain levels, and effectiveness of interventions. Medication administration records did not consistently document pain levels using the required scale. Interviews with the Director of Nursing confirmed the absence of comprehensive pain care plans and assessments for both residents. When asked about the adequacy of the care plans and assessments, the DON did not provide an answer. No additional information or justification for the lack of comprehensive pain management documentation was provided by facility leadership when requested by surveyors.
Inaccurate MDS Documentation for Residents with Serious Mental Illness
Penalty
Summary
Surveyors identified that the facility failed to ensure accurate and complete assessments for residents with serious mental illness, as required by regulatory standards. Multiple residents with diagnoses such as bipolar disorder, schizophrenia, major depression, anxiety, and psychotic disorders had Preadmission Screening and Resident Review (PASRR) Level I and II screenings indicating the presence of serious mental illness. However, these findings were not accurately documented in Section A1500 of the Minimum Data Set (MDS) assessments. In several cases, the MDS assessments incorrectly indicated that the residents did not have a serious mental illness, despite clear evidence from PASRR screenings and medical diagnoses. Interviews with facility staff, including social workers and the Director of Nursing, confirmed that the MDS assessments were coded incorrectly for these residents. Staff acknowledged the errors when questioned by surveyors, and no additional explanations were provided for the inaccuracies. The deficiencies were observed for all reviewed residents with serious mental illness and PASRR screenings, indicating a pattern of inaccurate documentation in the residents' comprehensive assessments.
Inadequate Training on Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure staff were adequately trained to use a specific type of Hoyer lift with support bars, resulting in a resident sustaining a bruise near their eye. The incident occurred when the resident was being transferred using the Hoyer lift, which has side bars that do not lock in an upward position. During the transfer, one of the bars fell and hit the resident on the left side of their face, causing a hematoma. The resident, who is cognitively intact and dependent on staff for transfers, reported that their eye still hurt weeks after the incident. The investigation revealed that the staff involved in the incident were not trained on the specific Hoyer lift before or after the event. The Assistant Director of Nurses and the Unit Manager did not implement any preventive measures or conduct staff training following the incident. The staff development coordinator confirmed that no competencies were in place for this particular lift, which was originally from the Veterans Administration. The facility's policy on safe transfers was not effectively implemented, as evidenced by the lack of staff training and preventive interventions to avoid future occurrences.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility did not ensure food was stored and served in accordance with professional standards for food safety. Staff failed to test the Sentinel sanitizing solution per manufacturer's instructions when testing the sanitizing sink used for dishwashing. The sanitizing sink was tested through the foam layer on top of the water, which is not the correct procedure. Additionally, the facility did not log or document the testing results, and the sanitizing sink was only tested daily instead of every 4 hours as required. This affected all 136 residents who receive food prepared by the facility kitchen. The unit refrigerator on 2E had multiple food items that were not labeled with the resident's name, and open food was not dated. The refrigerator was unclean, with stains of old food and liquid draining out of a plastic container with pickles. There was no current temperature log posted on the refrigerator, and temperatures had not been documented since December of 2023. This had the potential to affect all 41 residents who can use the resident's unit refrigerator on 2E. Interviews with staff revealed that the night shift was responsible for logging refrigerator temperatures and ensuring cleanliness, but this was not being done. The Nursing Unit Manager acknowledged the lack of a current temperature log and the presence of unlabeled and undated food items. The facility did not have a policy regarding the maintenance of resident unit refrigerators, contributing to the observed deficiencies.
Failure to Follow Recipe and IDDSI Guidelines for Pureed Food Preparation
Penalty
Summary
The facility did not ensure that food was prepared to conserve nutritive value, affecting 8 residents on a pureed diet. The Cooks Helper (CH-H) did not follow a recipe for preparing texture and modified consistency diet for pureed food. Instead, CH-H used an unmeasured amount of water and thickening agent, judging the texture by eye rather than following the IDDSI framework, which includes specific testing methods like the fork test. Additionally, CH-H did not use a liquid with nutritious value, opting for water instead of broth or another nutrient-rich liquid. The recipe binder available had serving sizes for 200 people, which CH-H found impractical for the current needs, leading to the omission of recipe use. During the survey, the Executive Chef (EC-K) and Director of Dining and Hospitality (Director-L) were informed about the issue. EC-K acknowledged that staff should be using the recipes and mentioned that they sometimes use broth for pureeing food. However, on this occasion, water was used. The surveyor noted that the recipe binder would be adjusted to include measurements for smaller serving sizes. The deficiency was communicated to the Chief Executive Officer (CEO-C), Assistant Administrator (AA-I), and Director of Nursing (DON-B).
Failure to Ensure Proper Catheter Care and Privacy
Penalty
Summary
The facility did not ensure that three residents with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and maintain their dignity. Resident 61 was observed multiple times with their catheter drainage bag system uncovered and laying on the floor, contrary to the care plan that required the drainage system to be stored inside a protective dignity pouch and not touch the floor. Despite multiple observations by the surveyor, the facility did not provide a privacy bag or any barrier between the drainage system and the floor for Resident 61. Resident 66, who had a recent urinary tract infection and required a urinary catheter, was also observed multiple times with their catheter drainage system uncovered and hanging on the bed frame. The surveyor noted blood-tinged urine in the drainage system bag, but no privacy bag or barrier was observed. The care plan for Resident 66 included monitoring for signs and symptoms of infection, but the facility failed to ensure the catheter drainage system was covered for privacy. Resident 63, with multiple diagnoses including Alzheimer's, chronic kidney disease, and a history of urinary tract infections, was observed with their catheter drainage bag uncovered and, at times, directly on the floor. The care plan for Resident 63 included interventions to keep the catheter patent and free of infection, but the facility did not consistently ensure the catheter drainage system was covered or off the floor. The surveyor noted the drainage valve tubing touching the ground, which was not addressed by the facility staff despite multiple observations and interviews with the Director of Nursing and Unit Manager.
Improper Insulin Administration
Penalty
Summary
The facility did not provide pharmaceutical services to meet the needs of each resident, specifically in the administration of insulin. A Licensed Practical Nurse (LPN) failed to safely administer insulin to a resident with Alzheimer's Disease, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. The LPN did not follow proper procedures for handling and administering the insulin, including not recapping the needle after drawing the insulin, waving the uncapped needle in the air, and walking into the resident's room with the uncapped needle. The LPN also donned gloves while holding the uncapped needle and administered the insulin without following the correct safety protocols. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the correct procedure for administering insulin includes recapping the needle after drawing the insulin and before bringing it to the patient. The DON expressed that staff should always recap the syringe after drawing up insulin, indicating a lapse in following established safety protocols. This deficiency was observed during a survey, and the facility's failure to adhere to proper pharmaceutical procedures was documented.
Improper Antibiotic Use for Viral Infection
Penalty
Summary
The facility did not ensure proper antibiotic use for a resident who was prescribed an antibiotic prior to obtaining a respiratory panel. The respiratory panel results documented that the resident was infected with the para-influenza virus, which does not respond to antibiotics. Despite this, the resident continued to receive antibiotic treatment without documented follow-up with the prescribing physician regarding the respiratory panel results. The resident, who had diagnoses including Alzheimer's disease, hypertensive heart disease, major depressive disorder, and anxiety disorder, was admitted to the facility and later exhibited symptoms such as cough and congestion. The physician ordered a course of Azithromycin and a respiratory panel. The respiratory panel confirmed the presence of the para-influenza virus, but there was no documentation that the physician was informed of these results or that the antibiotic treatment was reassessed. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility uses McGeer's criteria to identify infections and typically would not treat a viral infection with antibiotics. However, there was no documentation to support that the physician was made aware of the respiratory panel results or the rationale behind continuing the antibiotic treatment. The surveyor noted the lack of follow-up and documentation as a deficiency in the facility's management of the resident's drug regimen.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility did not ensure that its medication error rate was below 5 percent. During the observation of medication administration, staff made errors with two residents out of seven observed, resulting in an error rate of 6.45%. One resident was administered expired Novolin insulin, and another resident was given Aspirin with an illegible expiration date. The facility's policy requires that outdated or contaminated medications be removed and disposed of properly, and that insulin be labeled with a discard date. However, these protocols were not followed in these instances. For the first resident, the LPN administered 30 units of Novolin insulin that had been opened beyond the manufacturer's expiration period of 42 days. The Director of Nursing confirmed that the insulin should not have been administered. For the second resident, the LPN administered an 81 mg chewable Aspirin tablet from a bottle with an illegible expiration date. The Director of Nursing confirmed that the medication should have been discarded if the expiration date was not readable. Both incidents indicate a failure to adhere to the facility's medication administration policies, leading to a medication error rate above the acceptable threshold.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored and labeled according to professional principles. Surveyors observed multiple instances of undated, opened eye drops, unlabeled medications, and expired insulin in the medication carts. Additionally, insulin that required refrigeration was found unrefrigerated, and medications were improperly stored in latex gloves. A salad was also found in the medication fridge, which is against the facility's policy for medication storage. In the 2 Northwest Medication Room, surveyors found a tube of Procto Med HC and Hydrocortisone cream stored inside latex gloves, and a salad in the medication fridge. The refrigerator thermometer read 55 degrees, which is above the acceptable range for medication storage. Expired medications, including Lactulose and house stock bottles of Tab A Vite and Docusate Calcium, were also found. An open bottle of Pepsi and an open bag of Hot Stuff potato chips were observed on the counter behind the sink. The facility's Medication and Vaccine Storage policy states that medications should be stored safely, securely, and properly, with outdated or contaminated medications removed and disposed of properly. The policy also specifies that medications requiring refrigeration should be kept at temperatures between 36 F and 46 F. The surveyor's findings indicate that the facility did not adhere to these guidelines, leading to the observed deficiencies.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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