Manawa Com Nur Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Manawa, Wisconsin.
- Location
- 400 East 4th St, Manawa, Wisconsin 54949
- CMS Provider Number
- 525316
- Inspections on file
- 23
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Manawa Com Nur Ctr during CMS and state inspections, most recent first.
The facility assigned a food and nutrition services director who had not completed the required certification or education and had only recently begun a certified dietary manager course, with facility leadership mistakenly believing that course enrollment alone met regulatory requirements. This affected all 23 residents.
Surveyors found that menus did not specify portion sizes or differentiate between diet types such as NAS or NCS. Dietary staff relied on memory for serving sizes, and meal cards lacked detailed instructions. Pureed meals were divided without standardized scoops, and the menu used for all residents did not reflect individual dietary needs, potentially affecting all residents.
A registered nurse left a medication cart unlocked and unattended in a hallway while administering medications to a resident, with bottles of aspirin and Lactobacillus left on top of the cart. Facility policy requires medication carts to be locked or attended at all times, and only authorized staff to have access to medications. The DON confirmed these actions were not in compliance with policy.
Surveyors identified multiple failures in the infection prevention and control program, including incomplete infection control line lists for staff and residents, missing documentation of symptom resolution, and lack of required COVID-19 testing records. Observations revealed improper linen handling, such as placing a sheet from the floor back onto a resident's bed and using soiled washcloths without barriers during peri-care. Staff also failed to follow proper procedures for hand hygiene and glove changes, and placed washcloths in unsanitized sinks during catheter care.
A resident with severe cognitive impairment and a history of stroke did not receive routine nail care as required by their care plan and facility policy. Staff and documentation confirmed that the resident's nails had not been trimmed for over a month, and scheduled nail care was missed when a shower was not provided. The DON verified the lapse in nail care, resulting in a deficiency related to assistance with activities of daily living.
A resident with chronic health conditions was not provided with appropriate respiratory care, as there was no care plan or maintenance order for oxygen therapy despite ongoing use. Facility policy requiring weekly tubing changes and regular care plan updates was not followed, and the deficiency was confirmed by the DON during the survey.
A facility failed to prevent falls for two residents due to inadequate staff training. A CNA transferred a resident without a gait belt, resulting in a fall and injury, and later transferred another resident without a mechanical lift. The CNA returned to work without receiving necessary education on proper transfer techniques, despite a history of not following care plan interventions.
The facility did not have a qualified director of food and nutrition services, as the current Dietary Manager (DM-D) lacked necessary certifications and education. DM-D, hired in March 2024, was not enrolled in a Certified Dietary Manager program, despite intentions to do so. This deficiency could impact all 23 residents, as the facility was not seeking a new manager.
The facility failed to maintain complete medical records for four residents, as physician visit notes were missing. The issue arose after a provider switch in December 2023, which left the facility without access to the new provider's electronic portal. The DON confirmed the deficiency, and the ADON later received most of the missing notes from the physician's office.
A facility failed to thoroughly investigate an alleged neglect incident where a CNA transferred a resident without a gait belt, resulting in a fall and injury. The CNA returned to work without receiving necessary education, and was involved in another improper transfer. The investigation was not completed or submitted timely.
The facility did not ensure that two CNAs received mandatory QAPI training as part of their onboarding process. Despite being listed as a required training, records for CNA-I and CNA-J, hired in 2017 and 2015 respectively, showed no evidence of QAPI training. The Business Office Manager confirmed the lack of documentation, highlighting a gap in the facility's training records.
The facility failed to maintain a safe and clean environment after heavy rains caused water damage in several rooms, leading to mold-like growth and a mildew smell. Despite concerns from residents and family members, the facility did not immediately relocate affected residents or complete necessary repairs, leaving them in potentially unsafe conditions.
The facility failed to report abuse allegations involving four residents to the appropriate authorities in a timely manner. Incidents of verbal and alleged sexual abuse were not promptly reported, despite the facility's policy requiring immediate action. Staff interviews revealed delays in reporting due to the frequency of such incidents, and the Director of Nursing was unaware of some incidents until the surveyor's review.
The facility failed to investigate abuse allegations involving four residents. One resident verbally abused two others on separate occasions, and another resident allegedly sexually abused a second resident. The facility did not conduct thorough investigations into these incidents, and the DON was unaware of them until informed by the surveyor. The facility's policy requires immediate investigation of abuse allegations, but this was not followed, leading to a deficiency in addressing and investigating these incidents.
The facility failed to ensure timely reporting of allegations of abuse and misappropriation for four residents. An LPN administered lorazepam to a resident without a physician's order or consent, and this incident was not reported promptly. Additionally, a Hospitality Aide alleged that a CNA physically abused another resident with a hot washcloth, and a CNA alleged that the same LPN misappropriated lorazepam from another resident. These incidents were not reported to administration or the State Agency in a timely manner, resulting in a deficiency in the facility's compliance with regulations.
The facility failed to thoroughly investigate allegations of abuse and misappropriation involving four residents. Incidents included unauthorized administration of medication, physical abuse with a hot washcloth, and misappropriation of lorazepam. The investigations were incomplete, lacking interviews with all relevant staff and residents, and missing documentation in nursing notes.
A resident with severe cognitive impairment was administered lorazepam by an LPN without a physician's order or consent from the resident's POAHC. The LPN gave the medication to calm the resident, which was against the facility's policy. The incident was reported by a staff member, and an investigation confirmed the unauthorized administration.
The facility failed to ensure an RN worked for at least eight consecutive hours per day on multiple dates in November 2023, December 2023, and January 2024. The DON was aware of the requirement but was only on-call during the days without RN coverage.
The facility did not designate a qualified person to serve as the director of food and nutrition services. The Dietary Manager, who started as a dietary aide, did not complete an approved certification course and only received training from the non-accredited ServSafe program. The Registered Dietitian's feedback was not well received, and the Business Office Manager recognized the need for higher education for kitchen staff.
The facility did not ensure food was prepared and served under sanitary conditions, lacking an internal surface temperature monitoring device for the dishwasher. The Dietary Manager was unaware of the food code followed and did not know if the facility had logs or a process for monitoring the dishwasher's internal surface temperature. Observations showed inconsistent temperature readings, and the facility lacked additional temperature logs or a policy for monitoring.
The facility failed to monitor high-risk medications for three residents, specifically for potential side effects or adverse reactions of opioid medications such as fentanyl and morphine. The care plans and physician orders for these residents did not include necessary monitoring interventions, which was confirmed by the DON.
The facility failed to review vaccination history or offer the PCV20 vaccine to three residents. The DON indicated that new residents are offered the PCV20 vaccine, but existing residents were not audited or offered the vaccine due to the focus on COVID-19 and influenza vaccines. The ADON confirmed that only PCV13 and PPSV23 vaccines were audited.
Unqualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to designate a qualified individual to serve as the food and nutrition services director, as required by regulations. The person assigned to this role, identified as DM-H, had not completed an approved dietary manager or food service manager certification course, nor did they possess a national certification or an associate's or higher degree in food service management or hospitality. DM-H was hired in March 2024 and, although enrolled in a certified dietary manager (CDM) course, had only started the course approximately one month prior to the survey. Interviews with DM-H and the Director of Nursing (DON) confirmed that DM-H had delayed starting the course due to personal and staffing issues, and that facility leadership believed enrollment in the course was sufficient to meet requirements. This deficiency had the potential to affect all 23 residents residing in the facility.
Menus Lacked Portion Sizes and Diet Differentiation
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents in accordance with established national guidelines. Observations revealed that the menu did not specify portion sizes or differentiate between diet types such as No Added Salt (NAS) or No Concentrated Sweets (NCS). Dietary staff confirmed that there were no written instructions on the menu regarding portion sizes or specific dietary modifications for different resident needs. Instead, staff relied on their own knowledge of which scoops to use for serving, and meal cards did not contain portion sizes or indicate changes between diets. During meal service, pureed meals were divided evenly among residents without the use of standardized scoops, and any leftover food was given to a resident known to eat more, further indicating a lack of standardized portion control. Interviews with the Dietary Manager and the recently hired Registered Dietitian confirmed that the facility used a single menu for all residents, which lacked delineation between different diet types and did not specify portion sizes. The dietitian acknowledged that menus should be standardized for all diets and that the current system did not meet this requirement. The absence of an extended menu that clearly outlined differences between diet types and portion sizes had the potential to affect all 23 residents in the facility.
Unattended and Unsecured Medication Cart During Medication Pass
Penalty
Summary
Surveyors observed that medication storage and security protocols were not followed during a medication pass. A bottle of aspirin 81 mg and a bottle of Lactobacillus 100 mg, both intended for a specific resident, were left on top of an unlocked medication cart. The cart was left unattended in the hallway by a registered nurse while the nurse administered medications in residents' rooms, at times with the door closed. During this period, both staff and residents passed by the unattended cart. The nurse later confirmed that the medications should have been secured and that the cart should have been locked when not attended. Facility policies require that only authorized personnel have access to medications and that medication carts are locked or attended at all times. The policies also specify that the cart must be locked before entering a resident's room and that medications should never be left on top of the cart. The Director of Nursing acknowledged awareness of the incident and confirmed that the observed practices did not align with facility policy.
Infection Control Program Deficiencies and Improper Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by incomplete and inaccurate infection control line lists for both residents and staff. The line lists were missing critical information such as last symptom dates, times, and return-to-work dates, which are required by facility policy and CDC guidance. Additionally, the facility did not provide requested COVID-19 testing results for staff on day 5 and day 7, and several entries for residents and staff lacked documentation of symptom resolution or removal from precautions. The Director of Nursing confirmed these omissions and acknowledged that the facility used the test date as day one instead of day zero, contrary to standard protocols. Direct care observations revealed lapses in infection control practices during resident care and linen handling. For one resident with multiple comorbidities, including diabetes and chronic kidney disease, an Assistant Director of Nursing placed a sheet that had been on the floor back onto the resident's bed and later covered the resident with it, despite the resident indicating it was saturated with urine. During peri-care, a CNA used only two washcloths for both the front and back areas, placed soiled washcloths directly on the bed without a barrier, and failed to change gloves or perform hand hygiene before handling clean items and assisting with a lift. Both the CNA and the Director of Nursing confirmed these practices, which were inconsistent with facility policy and training materials. Further, improper linen handling was observed during catheter care for another resident, where a CNA placed washcloths in a sink without sanitizing it first, instead of using a basin as required. The CNA and the staff development nurse both acknowledged that this was not in accordance with facility procedures. These observed actions and documentation failures demonstrate a lack of adherence to established infection control protocols, increasing the potential for transmission of communicable diseases among residents and staff.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, a history of Marfan syndrome, dementia, and stroke, was not provided with routine nail care as required by facility policy. The resident's care plan specified that nail length should be checked and nails trimmed and cleaned on bath days and as necessary. Despite this, documentation and staff interviews revealed that the resident's nails had not been trimmed since a documented activity on 3/18/25, and on observation, the resident's fingernails were found to be clean but approximately 1/4 inch long. The resident required substantial to maximal assistance with activities of daily living, including bathing and nail care, due to their medical conditions and cognitive status. Further review showed that the resident was scheduled to receive a shower and associated care, including nail care, on a specific day, but the shower was not provided due to a missing key to the shower room. Documentation for that day did not indicate whether nail care was performed. Staff interviews confirmed that nail care should have been provided regardless of whether the shower occurred, and the DON verified that the last documented nail trimming was over a month prior. This failure to provide routine nail care as outlined in the care plan and facility policy constituted the deficiency.
Failure to Provide Necessary Respiratory Care and Services
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including type 2 diabetes mellitus with neuropathy, traumatic amputation, and chronic kidney disease, was not provided with the necessary respiratory care and services as required. The resident had an order for oxygen therapy to be administered as needed via nasal cannula for respiratory distress or discomfort, with instructions to titrate to maintain oxygen saturation above 90%. Despite this, there was no order in place for changing or maintaining the resident's oxygen equipment, nor was there a care plan for respiratory therapy documented at the time the resident was observed using oxygen. The facility's policy required weekly tubing changes and regular updates to the care plan by licensed nursing staff, but these were not followed. Surveyor observations and record reviews revealed that the resident was using oxygen for significant periods each day, yet the Treatment Administration Record did not include a maintenance order for oxygen tubing, and a care plan for oxygen therapy was not present until after the survey began. The Director of Nursing confirmed that a care plan should have been developed when the resident started using oxygen consistently and acknowledged the absence of an order for weekly tubing changes as required by facility policy.
Failure to Prevent Falls Due to Inadequate Staff Training
Penalty
Summary
The facility failed to provide adequate assistance to prevent falls for two residents, R3 and R5, as per their care plans. On August 19, 2024, a Certified Nursing Assistant (CNA-E) transferred R3 without using a gait belt, which was required according to R3's care plan. This resulted in R3 falling and sustaining a 4 cm forehead laceration and a subdural hematoma. Despite the incident, CNA-E was allowed to return to work on August 24, 2024, without receiving the necessary education on proper transfer techniques. On August 24, 2024, CNA-E was observed transferring R5 without using a mechanical lift, which was required by R5's care plan. This incident occurred before the facility completed its investigation into the previous incident involving R3. The facility's policies required that staff be educated as necessary during an investigation, but this was not adhered to in CNA-E's case. Interviews with staff revealed that CNA-E had a history of not following care plan interventions related to transfers, and management had been informed of this behavior previously. The facility's failure to educate CNA-E on following care plan interventions for transfers and allowing CNA-E to return to work without this education created a reasonable likelihood for serious harm, leading to a finding of immediate jeopardy. The facility's policies on abuse, neglect, and transfer procedures were not followed, contributing to the incidents involving R3 and R5.
Removal Plan
- Educate direct care/nursing staff on following care cards/care plan interventions related to transfer status.
- Update a binder to be kept at the nurses' station with care cards and individual service plans for residents.
- Conduct audits to ensure accuracy of transfer status.
Lack of Qualified Dietary Manager in Facility
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, which is a requirement for ensuring proper management and safety in food service operations. The Dietary Manager (DM-D) was identified as the lead cook and had been hired in March 2024. However, DM-D had not completed an approved dietary manager or food service manager certification course, nor did they possess any related education or national certification for food service management and safety. This deficiency was identified during a surveyor's visit to the kitchen, where DM-D confirmed their role as the Dietary Manager and mentioned plans to enroll in a Certified Dietary Manager (CDM) program. Interviews with the Director of Nursing (DON-B) and the Business Office Manager (BOM-C) revealed that DM-D was rehired in April 2024 to be the Dietary Manager after the previous manager left. Both DON-B and BOM-C acknowledged that DM-D was not currently enrolled in the CDM course, although there were intentions for DM-D to complete the course. The lack of a qualified director of food and nutrition services had the potential to affect all 23 residents residing in the facility, as the facility was not actively seeking a new Dietary Manager and relied on DM-D, who was not yet certified.
Incomplete Medical Records Due to Missing Physician Visit Notes
Penalty
Summary
The facility failed to ensure that medical records contained complete information for four residents, as physician visit notes were not readily accessible and available in their medical records. The surveyor reviewed the medical records of four residents, each with various diagnoses such as Alzheimer's disease, dementia, hypertension, anxiety, hypothyroidism, and arthritis. It was found that the physician visit notes were missing from the records of these residents, which is a requirement according to the facility's Long Term Facilities Retention Plan. The Director of Nursing (DON) acknowledged the issue, indicating that the facility had switched providers in December 2023 and had not yet set up access to the new provider's electronic portal system. This lack of access resulted in the unavailability of the physician visit notes. The Assistant Director of Nursing (ADON) later confirmed that the physician's office had sent most of the missing notes, except for one resident's notes, which were received later. This deficiency highlights the facility's failure to maintain complete and accessible medical records for its residents, as required by professional standards.
Failure to Investigate Alleged Neglect Thoroughly
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged neglect incident involving a resident, R3, who was transferred without a gait belt by a Certified Nursing Assistant (CNA-E). This incident resulted in R3 falling and sustaining a forehead laceration and hematoma. The facility's policy mandates that staff receive education on resident mistreatment and neglect, and that alleged perpetrators be removed pending investigation. However, CNA-E returned to work before the investigation was completed and without receiving the necessary education. The investigation revealed that CNA-E was involved in another improper transfer of a different resident, R5, who required a sit-to-stand lift for transfers. This transfer was conducted without the required equipment, further indicating a lapse in adherence to care plans. The Director of Nursing confirmed that staff education on falls and care plan interventions began only after CNA-E had returned to work, and the final investigation report was not submitted to the State Agency until after CNA-E's return.
Deficiency in QAPI Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNA-I and CNA-J) received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified during a review of staff education requirements. The facility provided a list of trainings that new employees are supposed to receive on their first day, which included QAPI training. However, upon reviewing one year of electronic and paper training records for CNA-I and CNA-J, the surveyor found no documentation of QAPI training for these staff members. CNA-I was hired on 5/16/17 and CNA-J on 7/22/15, indicating a long-standing oversight. The Business Office Manager, responsible for training and onboarding, confirmed the absence of QAPI training records for these CNAs, despite the facility's policy that such training should occur during orientation.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, and homelike environment for several residents, specifically those residing in rooms affected by water damage from heavy rains. On July 5, 2024, water from heavy rains penetrated the exterior walls of certain rooms, leading to the presence of a black and/or dark green, damp, and smudgeable substance on the baseboards and drywall surfaces. Additionally, a white fuzzy growth and a mildew-like smell were noted in some rooms. The 100 wing lounge was also affected, containing remodeling supplies and a bed stored in the center of the room, which contributed to the unclean environment. The surveyor's observations on July 26, 2024, confirmed the presence of these substances in the affected rooms, with varying degrees of growth noted on the baseboards and drywall. Family members and residents expressed concerns about the mold-like smell, with one family member indicating sensitivity due to asthma. Despite these concerns, the facility did not block off the lounge during repairs, and the affected residents continued to reside in their rooms without immediate relocation. The Nursing Home Administrator acknowledged the presence of the substances and indicated plans to repair the affected rooms within a few days to a week. However, at the time of the survey, the facility had not yet completed the necessary repairs or relocated the residents to unaffected rooms. The County Public Health Department and the facility's Medical Director provided guidance on testing and monitoring for respiratory symptoms, but the deficiency remained unaddressed at the time of the survey.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of abuse involving four residents to the Nursing Home Administrator, the State Agency, and local law enforcement in a timely manner. Specifically, incidents of verbal abuse by one resident towards two other residents were not reported promptly. Additionally, an incident involving alleged sexual abuse by another resident was not reported to the appropriate authorities. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed. The residents involved had varying levels of cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. One resident, who was involved in multiple incidents of verbal aggression, had a severe cognitive impairment, while the other residents had moderate to no cognitive impairment. Despite the facility's policy to monitor and report aggressive behaviors, staff failed to report these incidents immediately, citing the frequency of such occurrences as a reason for the delay. Interviews with staff revealed that incidents were often reported the day after they occurred, which is against the facility's policy. The Director of Nursing was unaware of some incidents until the surveyor's review, indicating a breakdown in communication and reporting procedures. The facility's failure to report these incidents in a timely manner represents a significant deficiency in adhering to established protocols for handling and reporting abuse allegations.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of abuse allegations involving four residents. On two occasions, one resident verbally abused another, and the facility did not conduct a comprehensive investigation into these incidents. Additionally, the same resident verbally abused a third resident, and again, the facility did not thoroughly investigate the matter. The Director of Nursing (DON) was unaware of these incidents until informed by the surveyor, indicating a lack of proper reporting and investigation procedures. Another incident involved a resident allegedly sexually abusing a second resident. The facility did not thoroughly investigate this allegation either. The resident accused of the abuse had a history of inappropriate sexual behavior, as noted in their care plan, but no updates were made to address the behavior towards other residents. The DON was also unaware of this incident, further highlighting the facility's failure to document and investigate reported incidents of abuse. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property requires immediate investigation of such allegations. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and investigation into the reported incidents. The DON's lack of awareness of these incidents suggests a breakdown in communication and reporting within the facility, leading to the deficiency in addressing and investigating abuse allegations.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse and misappropriation for four residents. On 4/9/24, an LPN administered a dose of lorazepam, a sedative medication, to a resident without a physician's order or consent from the resident's Power of Attorney for Healthcare (POAHC). This incident was not reported to administration or local law enforcement in a timely manner. Additionally, on 4/10/24, a Hospitality Aide alleged that a CNA physically abused another resident with a hot washcloth, but this incident was also not reported to administration or the State Agency (SA) in a timely manner. Furthermore, on 4/25/24, a CNA alleged that the same LPN misappropriated a dose of lorazepam from another resident on 7/17/23, and this incident was not reported to administration or the SA in a timely manner either. The facility's policy on abuse, neglect, and exploitation was not followed, and staff were not adequately educated on timely reporting of such incidents. The Director of Nursing (DON) confirmed that the incidents were not reported promptly and that staff education on timely reporting was insufficient. The facility's investigation revealed that the incidents were eventually reported to law enforcement and the SA, but not in a timely manner as required by the facility's policy. The failure to report these incidents promptly resulted in a deficiency in the facility's compliance with regulations regarding the reporting of abuse, neglect, and misappropriation. The facility's policy on abuse, neglect, and exploitation was not followed, and staff were not adequately educated on timely reporting of such incidents. The Director of Nursing (DON) confirmed that the incidents were not reported promptly and that staff education on timely reporting was insufficient. The facility's investigation revealed that the incidents were eventually reported to law enforcement and the SA, but not in a timely manner as required by the facility's policy. The failure to report these incidents promptly resulted in a deficiency in the facility's compliance with regulations regarding the reporting of abuse, neglect, and misappropriation.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
The facility did not ensure all allegations of abuse and misappropriation were thoroughly investigated for four residents. On one occasion, an LPN administered a dose of another resident's lorazepam to a resident without a physician's order or consent from the resident's Power of Attorney for Healthcare (POAHC). The facility's investigation was incomplete, as not all staff and residents were interviewed, and there was no documentation of the incident in the resident's nursing notes for the day in question. In another incident, a Hospitality Aide alleged that a CNA physically abused a resident with a hot washcloth. The facility's investigation included a statement from the aide and water temperature audits but failed to document an interview with the accused CNA or other staff members who worked with the CNA. Additionally, the facility did not interview other residents to determine if they were affected. A third incident involved an allegation of misappropriation of a resident's lorazepam by an LPN. The facility's investigation included a statement from a CNA but did not interview other staff members, including night shift nurses who conducted controlled substance counts with the LPN. The facility also failed to document the incident in the resident's nursing notes and did not thoroughly investigate the timeline and events surrounding the alleged misappropriation.
Unauthorized Administration of Lorazepam to Resident
Penalty
Summary
The facility did not ensure that a resident (R2) was free from chemical restraints, as a Licensed Practical Nurse (LPN-C) administered lorazepam to R2 without a physician's order or consent from the resident's Power of Attorney for Healthcare (POAHC). R2, who had severe cognitive impairment and was not prescribed lorazepam, was given the medication to stop pacing and calm down. This action was against the facility's policy, which requires written authorization from a physician for any chemical restraint. The incident was reported by a Hospitality Aide (HA-E) who witnessed LPN-C administering lorazepam to R2 and later observed R2 becoming unusually calm and relaxed. The facility's investigation confirmed that lorazepam was detected in R2's urine, and LPN-C had admitted to giving the medication to R2 because they were busy and could not handle the situation. The investigation also revealed that R2's medical record did not contain any documentation or physician's order for lorazepam on the day of the incident. Further review of the facility's records and interviews with staff corroborated the findings. The Director of Nursing (DON-B) verified that LPN-C's actions constituted a chemical restraint, which was against the facility's policy. The Police Chief (PC-G) also confirmed that the POAHC did not give consent for the administration of lorazepam to R2. The facility's investigation included statements from staff and drug panel results, which provided evidence of the unauthorized administration of lorazepam to R2.
RN Coverage Deficiency
Penalty
Summary
The facility did not ensure a Registered Nurse (RN) worked for at least eight consecutive hours per day seven days per week on multiple dates in November 2023, December 2023, and January 2024. This deficiency was identified through a review of the facility's nurse staffing schedules from October 2023 through January 2024, which revealed that the facility lacked RN coverage for at least 8 consecutive hours on nine specific dates. Interviews with the Business Office Manager (BOM) and the Director of Nurses (DON) confirmed awareness of the regulatory requirement but indicated that the DON was only on-call during the days without RN coverage, rather than physically present for the required hours.
Unqualified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility did not designate a person to serve as the director of food and nutrition services who met the required qualifications. The Dietary Manager (DM) hired on 9/20/23 did not complete an approved dietary manager or food service manager certification course or other related education. The DM, who started as a dietary aide, functioned more as a glorified cook and oversaw food ordering, cooking, and instruction for kitchen staff. The DM only received training from the ServSafe program, which is not an accredited food service program. The Registered Dietitian (RD) visited the facility once per month and was available by email when not on-site. The RD worked with the DM on kitchen processes but felt that their feedback and collaboration were not well received. The Business Office Manager (BOM) was under the impression that ServSafe was an approved course and indicated a need to implement a higher level of education and understanding for all kitchen staff.
Sanitary Conditions and Temperature Monitoring Deficiency
Penalty
Summary
The facility did not ensure food was prepared and served under sanitary conditions, potentially affecting all 23 residents. The facility lacked an internal surface temperature monitoring device to routinely monitor and ensure the warewashing machine (dishwasher) was functioning correctly. The Dietary Manager (DM) was unsure of the food code the facility followed and did not know if the facility had logs or a process for monitoring the internal surface temperature of the dishwashing machine. The Business Office Manager (BOM) confirmed that the facility used ServSafe, based on the FDA Food Code, as its standard of practice. The DM was not aware of internal surface temperature monitoring and did not know if the dishwashing machine used chemical or heat sanitization, deferring to the BOM for this information. The BOM confirmed that the dishwashing machine was a hot water sanitization machine, but the DM could not provide internal temperature monitoring logs. The surveyor observed the DM washing dishes in the dishwashing machine, noting that the temperature dials displayed a bouncing needle between 135-148 degrees F for the wash cycle and 186 degrees F for the rinse cycle. Despite this, the DM did not re-wash the dishes. The company that leases the machine verified it was working properly. Further observations showed the temperature dial displaying 140 degrees F for the wash cycle and 182 degrees F for the rinse cycle. After the machine's temperature was increased by the service company, the external temperature dial for the wash cycle reached 150 degrees F and the rinse cycle reached 190 degrees F, with the internal surface temperature of the cups measuring 160 degrees F. The DM verified the facility had one temperature monitoring log, which did not contain a month but was stated to be for February 2024. The log showed wash cycles documented as 168, 169, or 170 degrees F, and the DM stated staff averaged the reading when the needle bounced. The BOM confirmed the facility did not have additional temperature logs or a policy for internal or external temperature log monitoring.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility did not ensure high-risk medications were monitored for three residents (R2, R7, and R14) of five residents reviewed for unnecessary medications. Specifically, the facility failed to monitor these residents for potential side effects or adverse reactions of opioid medications such as fentanyl and morphine. The facility's Pain policy aims to recognize and manage pain to help residents attain or maintain their highest practicable level of well-being and to prevent or manage pain. However, the medical records and care plans for R2, R7, and R14 did not contain monitoring interventions for potential side effects or adverse reactions related to their opioid medications. For R2, the medical record showed an order for a fentanyl patch, but the care plan and physician orders lacked monitoring interventions for side effects or adverse reactions. Similarly, R7 had an order for morphine sulfate tablets, and R14 had an order for morphine sulfate oral solution, but neither of their care plans nor physician orders included monitoring interventions for potential side effects or adverse reactions. The Director of Nursing (DON) confirmed that monitoring was an expectation and verified the absence of these interventions in the residents' care plans and physician orders.
Failure to Administer PCV20 Vaccine to Residents
Penalty
Summary
The facility did not ensure that vaccinations were reviewed, offered, and administered for three residents (R14, R10, and R4) out of five residents reviewed for vaccines. Specifically, the facility failed to review the vaccination history or offer the PCV20 (Prevnar 20) vaccine to these residents. R14, who was admitted with diagnoses including Parkinson's disease, dementia, and hemiplegia, had received a PPSV23 vaccine in 2014 and a PCV13 vaccine in 2016 but was not offered the PCV20 vaccine. Similarly, R10, admitted with diagnoses including COVID-19, chronic kidney disease stage 3, dementia, hemiplegia, and diabetes, had received a PPSV23 vaccine in 2016 and a PCV13 vaccine in 2015 but was not offered the PCV20 vaccine. R4, admitted with diagnoses including Alzheimer's disease, COVID-19, and dementia, had received a PPSV23 vaccine in 2004 and a PCV13 vaccine in 2015 but was also not offered the PCV20 vaccine. The Director of Nursing (DON), who also served as the facility's Infection Preventionist, indicated that new residents are offered the PCV20 vaccine upon admission. However, the facility had not audited or offered the PCV20 vaccine to existing residents. The DON stated that the facility was focused on administering COVID-19 and influenza vaccines, which led to the oversight. The Assistant Director of Nursing (ADON) confirmed that they were assisting with follow-up on vaccines but had only audited residents for the PCV13 and PPSV23 vaccines, not the PCV20 vaccine.
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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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