Maplewood Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Allis, Wisconsin.
- Location
- 8615 W Beloit Rd, West Allis, Wisconsin 53227
- CMS Provider Number
- 525069
- Inspections on file
- 30
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Maplewood Center during CMS and state inspections, most recent first.
The facility did not accurately post daily nurse staffing information, with discrepancies found between the posted numbers of RNs, LPNs, and CNAs and the actual staff present on multiple shifts. Staff interviews confirmed that the night supervisor did not update the postings to reflect actual staffing, and the facility lacked a policy for daily nurse staff posting.
Multiple residents experienced injuries and unsafe transfers due to staff using incorrect or mismatched slings and mechanical lifts, lack of documentation of sling size in care plans, and inadequate staff training. Slings of various brands and sizes were stored haphazardly, and staff often selected slings based on availability rather than suitability, resulting in falls and fractures. The facility did not have a process to ensure the correct sling was used for each resident, and staff interviews confirmed confusion and lack of knowledge regarding proper sling selection and use.
Three residents with or at risk for pressure injuries did not receive timely and comprehensive wound assessments or consistent offloading of heels as required by care plans and facility policy. One resident developed new deep tissue injuries that staff were unaware of until identified by surveyors, and another resident's care plan lacked specific interventions for heel offloading. Delays in wound assessment occurred after hospital readmissions for two residents, and staff interviews revealed inconsistent practices in pressure injury prevention.
The facility did not ensure that nurses and nurse aides had the necessary competencies to care for all residents, including those with chest tubes, PICC lines, ventilators, and tracheostomies. Staff orientation was inconsistent, with agency and new staff often lacking adequate training and competency verification. Documentation of staff competencies was incomplete, disorganized, and sometimes relied on photocopied materials without individual identification. For a resident with a chest tube and PICC line, no staff or agency competencies were available during their stay, and required education was only provided after discharge.
The facility did not have a formal policy or procedure for new staff orientation or ongoing annual training, and staff training records showed that required topics such as effective communication, resident rights, abuse/neglect, infection control, and behavioral health were not completed by all staff. The facility relied on an online training platform, but not all necessary modules were included or completed, and there was no documentation to show that all required training was provided.
Three direct care staff members did not receive required effective communication training, as shown by a review of training records and transcripts. Despite the facility's procedure for onboarding and annual training through Relias, documentation was missing for these staff, indicating a lapse in training implementation or record-keeping.
A CNA did not have documented annual training on resident rights, despite the facility's use of an online training platform to assign mandatory modules. Review of training records revealed the absence of this required training for the CNA, potentially affecting all residents, and the facility could not provide a formal education policy to support their training process.
The facility did not provide or document mandatory QAPI training for an LPN, an RN, and three CNAs, as required for all staff. Review of training records and the annual training plan showed that QAPI was not included among the required modules, and there was no evidence that these staff received QAPI training as new hires or annually.
A CNA did not receive required annual infection control training, as shown by a review of staff training records. The facility's online training system did not document completion of the 'Infection Control: Essential Principles' module for this CNA, despite other infection control-related modules being completed. This lapse was identified during a review of training documentation for several staff members.
Three CNAs did not complete the required 12 hours of annual training, with deficiencies including incomplete hours and missing mandatory Abuse and Dementia modules. This lapse in staff education had the potential to impact all residents, as confirmed by facility leadership and record review.
The facility did not ensure that four out of five randomly selected direct care staff received behavioral health training as required by the facility assessment. Staff training records showed that some had no documentation of behavioral health training, while others only completed dementia-related or trauma-informed care modules, which did not meet the specific requirements. The annual mandatory training plan did not include behavioral health topics, and the facility could not provide evidence that staff received the necessary training upon hire or annually.
Multiple residents' tube feeding poles were found with dried feeding residue on the base and legs over several days, with some poles heavily soiled and difficult to adjust. Staff interviews revealed confusion about cleaning responsibilities, and the facility lacked a policy addressing the cleaning of tube feeding poles, resulting in ongoing unclean conditions.
The facility did not provide enough nursing staff to meet resident needs, leading to residents remaining in bed due to lack of assistance, missed rounds, and significant delays in meal service. Staff reported ongoing concerns about inadequate staffing, and leadership acknowledged difficulties in maintaining appropriate coverage, especially during staff absences.
Several residents prescribed Eliquis did not receive documented monitoring for side effects such as bleeding or bruising, despite care plans requiring daily checks. Staff interviews revealed that changes to the electronic charting system removed prompts for monitoring, and staff confirmed that monitoring was not being documented. Facility leadership stated that monitoring information was only in care plans and not in active orders or documentation, and no policy for anticoagulation monitoring was in place.
Surveyors found that drugs and biologicals, including various types of insulin and Tylenol, were not consistently labeled with resident names or dates when opened, and some were expired. Multiple medication carts and refrigerators contained these improperly managed medications. Nursing staff interviews revealed inconsistent knowledge and application of facility policies regarding medication labeling and expiration, and checks for expired or unlabeled medications were not reliably performed.
Surveyors found that food was not consistently prepared according to standardized recipes, with cooks omitting required thickeners and making substitutions based on personal preference rather than established guidelines. Food was frequently served cold and lacking in flavor, as confirmed by direct observation, resident interviews, and resident council feedback. Multiple residents with complex medical needs were affected, and staff acknowledged that deviations from recipes compromised the ability to ensure nutritional adequacy and safe food consistency.
Surveyors found that food was not stored or served according to professional standards, with open and undated food items in storage, improper hand hygiene by kitchen staff, and contaminated utensils being placed back into food ready to be served. These deficiencies affected the majority of residents receiving meals from the kitchen.
Two residents did not receive care in accordance with professional standards: one with a chest tube and PICC line lacked physician orders and a baseline care plan for device management, while another on anticoagulation therapy had multiple episodes of bloody or black stools documented by CNAs but not assessed or reported by nursing staff, despite care plan requirements for monitoring and physician notification.
Two residents with hearing impairments did not receive appropriate treatment or assistive devices, including audiology consults and consistent use of hearing aids, as required by their care plans and physician orders. Staff were observed not using communication devices, were unaware of the residents' hearing needs, and did not ensure hearing aids were in place, resulting in impaired communication and dignity.
A resident with quadriplegia and multiple medical conditions did not receive range of motion (ROM) exercises during personal care, despite care plans and CNA care cards specifying this intervention. Staff performed hygiene and repositioning but did not carry out or offer ROM, and interviews revealed uncertainty among staff about ROM requirements. The deficiency was confirmed through direct observation and interviews with both staff and the resident.
A resident with vitamin B deficiency anemia received daily injections of methylcobalamin B12 at a dosage and formulation not matching the physician's order or the MAR, due to an incorrect transcription. The resident stored and supplied her own medication, which was administered by nurses for several months without the order being corrected.
Three medication errors were observed, including the improper crushing of Sodium Chloride for a resident with a G-tube and the administration of an incorrect dose of vitamin D and the wrong type of multivitamin to another resident. These actions resulted in a medication error rate above the required threshold, with staff interviews and record reviews confirming the errors and uncertainty regarding proper medication administration.
A resident with multiple chronic conditions receiving hospice care did not have required hospice progress notes or communication documented in their medical record. Staff interviews revealed inconsistent practices and confusion about who was responsible for collecting and maintaining hospice documentation, resulting in a lack of required records and communication between the facility and hospice.
Two residents with indwelling medical devices did not receive proper Enhanced Barrier Precautions (EBP) as required by facility policy and physician orders. Staff were observed not using gowns or performing hand hygiene during high-contact care activities, and were often unaware of the residents' need for EBP. EBP signage and PPE were missing or not used appropriately, and equipment was not disinfected between uses.
The facility did not ensure that staff were trained or competent to provide respiratory care to residents with ventilators or tracheostomies, resulting in family members performing critical care tasks and residents not receiving required respiratory therapy. Multiple shifts lacked a respiratory therapist, and nursing staff, including LPNs and agency nurses, were not consistently able or authorized to perform necessary respiratory interventions. Facility policies did not clearly assign responsibilities or provide for adequate supervision, leading to immediate jeopardy for residents requiring specialized respiratory care.
A ventilator-dependent resident with multiple comorbidities developed new shortness of breath during the night shift. The RT increased the resident's oxygen flow but did not perform a comprehensive assessment, document follow-up, or communicate the change to nursing staff or the physician. No further monitoring or assessment was conducted, and the resident was later found deceased, with staff interviews confirming that the change in condition was not properly addressed or reported.
Several ventilator-dependent residents were moved to different rooms and units without being given individualized written notice or the opportunity to choose their new room. The facility sent a general letter about a reorganization plan but did not provide specific room options or solicit resident or family preferences. Staff interviews confirmed that the moves were made for operational convenience, and affected residents and their representatives were not properly informed or consulted about the changes.
Several ventilator-dependent residents and their representatives were not informed of or given the opportunity to refuse room transfers that were conducted for staff convenience. Communication about the moves did not include information about the right to refuse, and some residents or their POAs were not notified of the specific room changes until after they occurred. Staff confirmed that the option to refuse was not offered, despite knowing residents have this right.
During a facility-wide reorganization, several ventilator-dependent residents were moved to new rooms and units without being offered a choice or individualized information about available rooms. Communication to residents and their representatives was limited to a general letter, and some were not notified of their actual room assignment until after the move. Staff confirmed that the moves were made for operational convenience, and documentation showed that resident preferences were not solicited or honored.
A facility did not thoroughly investigate an allegation of neglect after a resident with complex medical needs was sent to the hospital in a wet condition and without necessary personal items. The facility's investigation failed to include interviews with night shift staff or determine when the resident was last checked or changed prior to transfer, resulting in an incomplete assessment of the incident.
A resident with severe cognitive impairment and complex medical needs had a care plan that was not updated after the family was observed performing suctioning without staff supervision, and after a facility policy change prohibited the use of a camera device in the resident's room. Staff interviews confirmed that the care plan did not reflect these significant changes, leaving staff without current guidance or accurate documentation.
A CNA did not change gloves or perform hand hygiene between cleaning a resident's bowel movement and providing pericare, despite the resident's history of recurrent UTIs and MDRO precautions. This action was not in accordance with the facility's infection control policy, which requires proper hand hygiene during care tasks.
A resident with complex medical needs vomited, prompting a KUB order, but the facility failed to notify the resident's representative of this change in condition, contrary to their policy. The oversight was acknowledged by the RN Supervisor, and the incident was reported to the DON and NHA.
Two residents filed grievances regarding care concerns, including long call light response times and improper handling during transfers. The facility failed to conduct thorough investigations, lacked documentation, and did not provide written responses to the residents, highlighting deficiencies in their grievance handling process.
The facility failed to report three separate allegations of abuse involving residents to the State Survey Agency. In one case, a resident overheard a CNA being verbally abusive, but the incident was not reported. Another case involved a resident's representative alleging neglect, which was not reported promptly. The third case involved a family member being verbally aggressive, but the facility did not report it as required.
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents. In one case, a resident's family member was reported to be verbally aggressive, but no comprehensive investigation was conducted. In another case, a resident reported overhearing a CNA being verbally abusive to another resident, but the night nursing supervisor did not conduct a thorough investigation. The facility did not submit a complete investigation to the State Survey Agency, and conflicting information was provided regarding the actions taken.
A resident with complex medical conditions was found with a foam dressing on his back without a physician order. The dressing, dated eight days prior, was applied for protection due to family concerns about a resolved wound. Nursing staff failed to ensure proper documentation and orders, leading to a deficiency in care standards.
A resident with chronic respiratory failure experienced two incidents where a heating and air conditioning valance fell open, splashing condensate and debris onto their bed. Despite immediate reporting and maintenance intervention, the facility failed to conduct a thorough investigation or implement preventive measures after the first incident, leading to a recurrence. Inconsistent maintenance documentation and inadequate inspections contributed to the deficiency.
The facility failed to manage medications properly for two residents, resulting in missing documentation for controlled substances and unavailability of a critical medication. One resident's controlled medication records were incomplete, while another did not receive Mexiletine due to delivery issues and staff confusion over reordering procedures. These deficiencies highlight a breakdown in the facility's medication management system.
A facility experienced a 16% medication error rate involving three residents. Errors included incorrect administration of Sennosides and Polyethylene Glycol for one resident, insufficient water added to Polyethylene Glycol for another, and the wrong type of Aspirin given to a third resident. These errors were observed by surveyors and confirmed by facility staff.
The facility failed to adhere to Enhanced Barrier Precautions for two residents, as staff did not wear gowns during high-contact care activities. One resident with a tracheostomy and gastrostomy did not receive proper PPE use during incontinence care and dressing changes, while another resident with a feeding tube did not have proper PPE use during medication administration. These deficiencies were noted despite clear signage and orders, indicating a lapse in infection control practices.
The facility failed to maintain an effective infection control program for a resident with parainfluenza. Staff were observed interacting with the resident without masks, and the resident was seen coughing in common areas without a mask. Staff were generally unaware of the proper precautions, and hand hygiene was not performed between assisting residents. These lapses had the potential to affect 31 residents on the unit.
The facility failed to ensure the PASRR process was conducted accurately for a resident with a serious mental illness. The resident's Level 1 PASRR Screen indicated a 30-day exemption, but the facility did not initiate a new screen after the exemption period, missing the required Level II Screen. Interviews revealed a lack of clarity and responsibility among staff regarding the PASRR process.
A resident with multiple diagnoses missed a scheduled GI consult due to the facility's failure to ensure the appointment was attended. The consult, initially scheduled for early March, was not completed until mid-May, with no documentation explaining the delay. Staff were unaware of the reasons behind the missed appointment, highlighting a lapse in following the resident's care plan and professional standards.
The facility was unaware that the high temperature dish machine was not functioning correctly, and lacked a process to verify its internal temperature, potentially affecting all 95 residents. The temperature gauges did not indicate appropriate sanitizing temperatures, and the dish machine's conveyor belt was also not working.
The facility lacked a comprehensive water management plan and failed to follow COVID-19 transmission-based precautions. Staff were observed entering a COVID-19 positive resident's room without appropriate PPE, and annual fit testing for N95 masks was not conducted as required.
A resident alleged that another resident entered their room and physically assaulted them. The accused resident was moved to another unit without increased supervision, potentially putting other residents at risk. The facility acknowledged that no specific interventions were implemented to safeguard the new unit's residents.
A resident admitted with a Foley catheter had no documented diagnosis or medical justification for its use, and the facility failed to assess or plan for its removal. Additionally, the facility did not develop a care plan for the resident's constipation, leading to significant constipation and an emergency room visit for fecal impaction. The facility's policies on catheter care and bowel movement monitoring were not adequately followed.
The facility failed to keep two residents free from unnecessary drugs by prescribing medications for conditions not documented in their diagnoses. One resident was given Memantine for depression without a diagnosis of depression, and another was prescribed Phenytoin for seizures without a documented diagnosis of seizures.
The facility failed to ensure proper labeling, expiration checks, and temperature control for medications. Insulin pens and vials were found open and undated, and expired medications were discovered in a medication cart. The refrigerator storing medications was also found to be below the recommended temperature range, with no corrective action taken.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information posted accurately reflected the actual staff hours available to care for the 99 current residents. On multiple occasions, the posted staffing information did not match the actual nursing schedule. For example, on one night shift, the posted document indicated two RNs, three LPNs, and seven CNAs, while the actual schedule showed three RNs, two LPNs, and five CNAs. Similar discrepancies were found on other dates, with the posted numbers of RNs, LPNs, and CNAs not matching the actual staff present according to the nursing schedule. Interviews with facility staff revealed that the night supervisor was responsible for updating the night shift staffing information but did not revise the document to reflect the actual staff on duty. The DON confirmed the discrepancies between the posted staffing and the actual schedule. Additionally, the staff scheduler stated that she updated the day and evening shifts, while the night supervisor handled the night shift. The facility did not have a policy in place for daily nurse staff posting, contributing to the inconsistencies observed.
Failure to Ensure Safe Resident Transfers and Proper Use of Mechanical Lifts and Slings
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and the correct use of assistive devices to prevent accidents, as evidenced by multiple incidents involving improper use of mechanical lifts, sit-to-stand devices, and slings. Staff did not consistently use the correct lift or sling size, and there was no established process to ensure that residents being transferred had the appropriate sling for their needs. Observations revealed that slings of various brands and sizes were stored haphazardly, with staff often selecting slings based on availability rather than suitability, and sometimes using the same sling for multiple residents. In several cases, staff were unaware of the correct sling size or type to use for specific residents, and sling sizes were not documented in care plans or assignment sheets. Several residents experienced adverse events as a result of these deficiencies. One resident fell from a Sara Steady and suffered a displaced spiral fracture of the left femur when the device was used for a transfer it was not designed for. Another resident slid off a sling that had been left under them in a wheelchair, resulting in a right humerus fracture, despite facility policy requiring slings to be removed after transfer. Additional residents were observed being transferred with slings of incorrect size or type, and some were left sitting on slings in violation of policy. Staff interviews confirmed a lack of training and knowledge regarding sling selection, use, and documentation, with some staff admitting to using whatever sling was available and not knowing the correct procedures. The facility's own policies and the manufacturers' instructions for the lift equipment require the use of the correct sling, matched by size and manufacturer, and prohibit the use of slings that are not specifically designed for the equipment in use. Despite these requirements, the facility did not maintain an organized system for sling storage, did not ensure slings were labeled or matched to residents, and did not provide adequate training or documentation for staff. The lack of a systematic process for ensuring safe transfers and proper equipment use led to multiple incidents of resident harm and created an environment with ongoing potential for more than minimal harm.
Failure to Provide Timely Pressure Ulcer Assessment and Prevention
Penalty
Summary
Surveyors identified that the facility failed to provide necessary pressure ulcer care and prevention for three residents with or at risk for pressure injuries. For one resident with quadriplegia and multiple pressure injuries, the facility did not perform a comprehensive assessment of the resident's wounds until seven days after readmission from the hospital. During this period, multiple observations were made of the resident's feet and heels resting directly on the air mattress without offloading, despite care plans specifying the need for offloading and the use of positioning devices. The air mattress was also repeatedly set at incorrect weights, not matching the resident's actual weight. A new pressure injury was discovered on the resident's right lateral foot by the surveyor, which the facility was unaware of until it was pointed out during the survey. Staff interviews confirmed inconsistent practices regarding offloading and assessment of the resident's feet, and documentation of wound assessments was lacking for the period following readmission. Another resident, also with quadriplegia and at high risk for pressure injury development, was observed multiple times with heels resting directly on the mattress or pillows, not being properly offloaded. The care plan for this resident did not include specific interventions for offloading the heels or a repositioning schedule, and there was no documentation of refusal of offloading interventions. Staff interviews revealed a lack of clarity and consistency in implementing heel offloading, and the resident's family reported that repositioning was not consistently performed by staff. A third resident with a chronic stage 4 sacral pressure injury was hospitalized and readmitted on two separate occasions. In both instances, the facility did not complete a comprehensive assessment of the resident's pressure injury until two days after readmission. This delay in assessment was not in accordance with the facility's own policy, which requires comprehensive and timely wound assessments upon admission or readmission. The findings indicate that the facility did not ensure timely and thorough assessment, documentation, and implementation of individualized interventions to prevent the development or worsening of pressure injuries for residents at risk or with existing wounds.
Failure to Ensure Nursing Staff Competency for Specialized and General Care
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies and skill sets to care for residents with specialized needs, including those with chest tubes, PICC lines, ventilators, and tracheostomies, as well as for general nursing competencies. Surveyors found that 16 staff members lacked documented competencies for chest tube and PICC line care, and 12 out of 47 staff reviewed had incomplete competencies for ventilator and tracheostomy care. Additionally, there were shifts where no competent RN was available to oversee the ventilator unit, and the facility did not have an effective process to ensure all new and agency staff had the required competencies. Interviews with staff revealed significant gaps in orientation and competency verification. Agency nurses reported receiving minimal orientation, often limited to a tour and basic computer access, with an 'ask and learn as you go' approach. New LPNs described inadequate orientation, lacking checklists and specific training for ventilator care. The staff development process was in transition, with the new Staff Development Specialist still developing a more robust system. There were also issues with the orientation checklist process, as checklists were often lost or not completed, and agency staff did not receive competency checklists at all. The facility relied on agencies to confirm competencies, but agencies reported not providing training on chest tubes or PICC lines. Documentation provided to surveyors regarding staff competencies was incomplete and disorganized. For ventilator and tracheostomy care, training packets were missing key components such as skills checklists, and some test documents were photocopied and placed in multiple staff files without individual identification. There was no master list to cross-reference which staff had completed required training, and the documentation did not consistently include names or dates. For the resident with a chest tube and PICC line, no staff or agency competencies were provided for the period the resident was in the facility, and education on these topics was only provided after the resident had left. These deficiencies were confirmed through interviews, record reviews, and direct observation by surveyors.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, as required by their own facility assessment. The assessment indicated that staff should be trained to meet the needs of all residents, including specific competencies such as dementia care, infection control, and abuse prevention. However, the facility did not have a formal policy or procedure for new staff orientation or ongoing annual training for existing staff. When requested, the Director of Nursing (DON) was unable to provide documentation of such policies or procedures. A review of training transcripts for selected staff members, including LPNs, RNs, and CNAs, revealed that required training topics such as effective communication, resident rights, abuse/neglect/exploitation, QAPI, infection control, compliance and ethics, and behavioral health were not completed either at hire or annually. The facility relied on an online training platform (Relias) for staff education, but not all required modules were included in the training plan, and not all staff had completed the necessary training. Sign-in sheets and agendas from staff meetings did not cover the required topics, and not all selected staff had evidence of attendance. Despite the facility's claim that all employees are registered in Relias and assigned mandatory training modules upon hire, the documentation provided did not demonstrate that all required training was completed by the staff reviewed. The facility also lacked a formal, documented policy and procedure for both onboarding and annual training, as well as evidence that all required training topics were addressed for all staff members.
Failure to Provide Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that three out of five randomly selected direct care staff members received effective communication training, as required. During the survey, the Director of Nursing (DON) was unable to provide documentation that Certified Nursing Assistants (CNAs) hired on specific dates had completed the necessary communication training. One CNA had no record of any communication training since hire, another had not completed the training since hire, and a third had only completed a dementia communication course several years prior, with no evidence of annual communication training. The facility's training records, maintained through the Relias online platform, did not show completion of the required modules for these staff members. The surveyor requested the facility's policies and procedures for new employee and annual training, as well as documentation of completed training for selected staff. The facility provided a procedure outlining the use of Relias for onboarding and annual training, listing communication-related modules as part of the mandatory training plan. However, despite these procedures, the training transcripts for the three CNAs did not reflect completion of the effective communication training, indicating a lapse in the implementation or documentation of the facility's training program.
Annual Resident Rights Training Not Documented for CNA
Penalty
Summary
The facility failed to ensure that all direct care staff received annual training on resident rights, as required. During a review of training records for five randomly selected direct care staff, it was found that one Certified Nursing Assistant (CNA) had not received documented resident rights training since 2020. The facility utilizes an online training platform, Relias, to assign and track mandatory training modules, including one on safeguarding resident rights. However, the CNA in question did not have any record of completing this required training annually, as confirmed by a review of the Relias transcripts provided by the Director of Nursing. When the surveyor requested documentation and policies regarding staff training, the facility was unable to provide a formal education policy but did submit a procedure outlining how staff are registered and assigned training modules through Relias. Despite this procedure, the lack of documentation for the CNA's resident rights training remained unresolved, indicating a lapse in the facility's process for ensuring and verifying completion of mandatory annual training for all staff. This deficiency potentially affected all 108 residents in the facility.
Failure to Provide Mandatory QAPI Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that all direct care staff received mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. During the survey, the surveyor requested documentation of QAPI training for five randomly selected direct care staff members, including an LPN, an RN, and three CNAs. The Director of Nursing (DON) stated that the facility uses Relias, an online training platform, for staff education and provided training transcripts for the selected staff. Upon review, none of the five staff members had documentation of QAPI training, either as new hires or as part of annual training. Further review of the facility's annual training plan revealed that QAPI training was not included among the mandatory training modules assigned to staff. The Nursing Home Administrator (NHA) confirmed that while there was a procedure for registering employees in Relias and assigning annual training modules, there was no formal education policy or documentation indicating that QAPI training was provided. The lack of QAPI training documentation affected all 108 residents in the facility, as all staff are required to be trained in QAPI to ensure quality care.
Failure to Provide Annual Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that one of five randomly selected direct care staff received annual infection control training, as required by their infection prevention and control program. Specifically, a Certified Nursing Assistant (CNA) did not have documentation of completing the 'Infection Control: Essential Principles' training since more than four years prior, despite having completed other infection control-related modules such as hand hygiene and urinary tract infection prevention. The surveyor reviewed training transcripts for several staff members and found that only this CNA lacked the required annual infection control training. During the survey, the Director of Nursing (DON) and Nursing Home Administrator (NHA) were unable to provide evidence of the CNA's completion of the required training. The facility uses an online training platform, Relias, to assign and track mandatory training modules for all staff, including infection control. However, the records provided did not show that the CNA in question had completed the annual infection control module, indicating a lapse in the facility's process for ensuring and documenting compliance with mandatory infection control training requirements.
Failure to Ensure CNAs Completed Required Annual Training
Penalty
Summary
Three of five reviewed Certified Nursing Assistants (CNAs) did not complete the required annual 12 hours of educational training, as documented by surveyor review of employee records. Specifically, one CNA completed only 1.25 hours, another completed 10.5 hours, and a third, while completing 12 hours, did not include mandatory Abuse and Dementia training within those hours. The facility assessment indicated that all staff are required to have annual education and competencies, including dementia and abuse prevention training, but documentation for these requirements was not provided for the three CNAs in question. The surveyor's findings were based on a random selection of CNA records and interviews with facility leadership and the Staff Development Specialist, who confirmed awareness of the training requirements and the deficiencies in the reviewed records. The lack of completed training, particularly in abuse and dementia care, had the potential to affect all 108 residents in the facility, as these competencies are essential for quality care and resident safety.
Failure to Provide Required Behavioral Health Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that 4 out of 5 randomly selected direct care staff received behavioral health training as required by the facility assessment, potentially affecting all 108 residents. The facility assessment documented that residents with psychiatric and mood disorders, including psychosis, impaired cognition, depression, PTSD, anxiety, and behavioral symptoms, require care and interventions from staff trained in behavioral health. Upon review, it was found that some staff had no documentation of behavioral health training, while others had only completed dementia-related or trauma-informed care modules, which did not meet the specific behavioral health training requirements outlined in the facility assessment. The surveyor requested and reviewed the facility's policies and staff training records, noting that the annual mandatory training plan did not include behavioral health topics. The Director of Nursing confirmed that Relias, the facility's online training platform, was used for staff education, but the modules assigned did not cover behavioral health as required. The Nursing Home Administrator acknowledged the lack of a formal education policy and the absence of behavioral health training in the annual training plan. As a result, the facility did not provide evidence that staff received the necessary behavioral health training upon hire or annually, as required by their own assessment.
Failure to Maintain Cleanliness of Tube Feeding Poles
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for five residents who used tube feeding poles. Over multiple days, the bases of these residents' tube feeding poles were observed to have dried feeding residue, with some poles having significant accumulations on multiple legs and even clumps of dried feeding. Observations were made on several occasions, and in one instance, a family member reported that the pole had been dirty for months, making it difficult to adjust due to the buildup. Interviews with facility staff revealed confusion regarding responsibility for cleaning the tube feeding poles. A housekeeping aide stated uncertainty about whether cleaning the poles was her responsibility or that of the CNAs, and admitted that she had not cleaned any of the poles in the past month. The RN Supervisor and Administrator both indicated that housekeeping was responsible for cleaning the poles, but the facility's provided cleaning policy did not address tube feeding poles specifically. No additional policy or explanation was provided for the lack of cleaning, and the issue persisted despite being brought to the attention of facility leadership.
Insufficient Nursing Staff Resulting in Missed Care and Delayed Services
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several instances where care was not delivered as required. On one occasion, a certified nursing assistant (CNA) reported being the only CNA on a unit with eight residents requiring two-person assistance with mechanical lifts, leading to four residents remaining in bed due to lack of available staff. Additionally, staff were unable to round on residents during a night shift because a CNA was absent, as documented in the facility's schedule. Staff interviews confirmed that concerns about inadequate staffing had been communicated to facility leadership, but the issue persisted, particularly on units with higher acuity residents. Surveyors also observed delays in meal service, with residents in the dining room receiving breakfast trays 1.5 hours after the scheduled time due to insufficient staff to pass trays and assist with feeding. The facility's staffing assessment and schedules indicated discrepancies between planned and actual staffing levels, with staff coordinators and leadership acknowledging challenges in maintaining adequate coverage, especially when call-ins occurred. The facility relied on agency nurses but not agency CNAs, and staff often had to be pulled from other units to cover shortages. Leadership interviews revealed uncertainty about how staffing levels in the facility assessment were determined, as the previous administrator was responsible for its creation.
Failure to Monitor Anticoagulant Side Effects as Directed in Care Plans
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not providing appropriate monitoring for residents prescribed Eliquis, an anticoagulant. Four residents were identified as receiving Eliquis without documented monitoring for side effects such as bleeding or bruising, despite care plans indicating that such monitoring should occur at least daily. The care plans for these residents specifically included interventions to monitor for signs of active bleeding, but there was no evidence in the medical records, Medication Administration Records (MARs), or Treatment Administration Records (TARs) that this monitoring was being performed or documented. Interviews with facility staff revealed that the transition to a new electronic charting system resulted in the removal of prompts or reminders for staff to monitor for medication side effects. Certified Nursing Assistants (CNAs) and nursing staff reported that previous printed materials, which included monitoring instructions, were no longer available after the system change. Staff members, including LPNs and RN supervisors, acknowledged that monitoring for bleeding should be in place for residents on blood thinners, but confirmed that such monitoring was not being documented or ordered in the current system. The Director of Nursing (DON) and Director of Clinical Operations stated that monitoring information was only present in the care plan and not in active orders or documentation, and believed that documentation was not required beyond the care plan. Additionally, the facility did not have a policy for anticoagulation or high-risk medication monitoring. The Director of Clinical Operations stated that the pharmacy advised monitoring was not necessary for Eliquis, and that it was sufficient for the information to be in the care plan. However, surveyors clarified that daily monitoring should be documented as indicated in the care plans. Despite being informed of the lack of monitoring documentation, facility leadership did not provide further explanation or evidence that monitoring was occurring for the affected residents.
Failure to Properly Label, Date, and Store Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards and facility policy. Multiple medication carts and medication refrigerators contained insulin pens and vials that were either expired, not labeled with the resident's name, or not dated when opened. Specific examples included expired Basaglar and Humalog insulin, Lantus Solostar insulin without a resident's name, and several instances of Lispro, Glargine, Novolin N, and Levemir insulin that were not dated when opened or not labeled with the resident's name. Additionally, a bottle of Tylenol was found with an expired date. Interviews with nursing staff revealed a lack of consistent knowledge and adherence to the facility's policies regarding medication labeling and expiration dating. Some LPNs were unaware of the required timeframes for insulin use after opening, and others acknowledged that medications should be dated and labeled but failed to ensure this was done. The facility's own policies required dating vials or devices after first use and specified shortened end-of-use dating for certain products, but these procedures were not consistently followed. The surveyors also found that the process for checking medication carts and refrigerators for expired or improperly labeled medications was not reliably implemented. Nurses reported that checks were supposed to occur monthly with random audits, but expired and unlabeled medications were still present. The lack of proper labeling and dating was observed across multiple units and involved several residents' medications, indicating a systemic issue with medication management practices within the facility.
Failure to Prepare and Serve Palatable, Safe, and Nutritious Food
Penalty
Summary
Surveyors identified that the facility failed to ensure food was prepared and served in a manner that conserved nutritive value, flavor, and maintained safe and appetizing temperatures. Observations revealed that the lead cook did not follow standardized recipes for preparing pureed foods, specifically omitting required thickeners and substituting additional broth and meat to achieve desired consistency and flavor. The cook stated this was based on personal experience rather than adherence to recipes, and acknowledged that substitutions were made frequently to improve taste. The dietician and speech language pathologist both confirmed that recipes should be followed to ensure nutritional adequacy and safety, and expressed concern that deviations could not guarantee consistent nutrition or safe food texture for residents. Surveyors also documented that food served to residents was often cold and lacked flavor. During a test tray observation, food temperatures were recorded well below recommended hot holding standards, with eggs at 90.7°F, toast at 81.5°F, and coffee at 118.2°F. Residents consistently reported through interviews and resident council meetings that food was served cold, both in the dining room and in resident rooms, and that the quality and palatability of meals were poor. Resident council minutes over several months reflected ongoing complaints about cold food and lack of flavor, with staff responses indicating attempts at training and use of plate warmers, but with continued dissatisfaction from residents. Multiple residents affected by this deficiency had significant medical conditions, including congestive heart failure, hypothyroidism, anemia, chronic kidney disease, diabetes, hemiplegia, and dementia. Cognitive assessments indicated that some residents were cognitively intact while others had moderate to severe impairment. Despite these vulnerabilities, the facility did not ensure that food preparation and service met the required standards for safety, nutrition, and palatability, as evidenced by both staff interviews and direct resident feedback.
Failure to Store and Serve Food According to Professional Standards
Penalty
Summary
The facility failed to store and serve food in accordance with professional standards for food service safety, affecting 95 of 108 residents who receive food from the kitchen. Surveyors observed multiple instances of partially used and undated food items in dry storage and walk-in coolers/freezers, including open bags of graham cracker crumbs and noodles, undated containers of chicken and ham base, and a dented can of condensed milk stored with undamaged cans. Some food items were left uncovered and open to air, and a box of cups was found on the floor. These practices were not in line with the facility's own policies, which require all opened food to be dated, sealed, and stored properly to prevent contamination and spoilage. In addition to improper food storage, surveyors observed repeated failures in hand hygiene among kitchen staff. Staff members were seen moving between tasks and kitchen stations, touching unclean surfaces such as clipboards, pens, ear buds, phones, hairnets, and their own bodies, and then handling food or clean utensils without washing their hands as required by facility policy. Handwashing, when performed, was often inadequate, with some staff washing for less than five seconds instead of the required twenty seconds. There were also instances where staff used bare hands to touch clean serving utensils and plate holders, and then used these items to serve food to residents without proper sanitation in between. Contaminated utensils were also placed back into food that was ready to be served, further increasing the risk of cross-contamination. For example, after a thermometer was dropped into soup, a staff member used a clean utensil to retrieve it but then placed the utensil back on the clean tray line without sanitizing it. Another staff member was observed placing a ladle that had come into contact with their shirt back into a food container. These actions were contrary to both facility policy and professional standards for food safety, and were directly observed by surveyors during meal service.
Failure to Ensure Physician Orders and Monitoring for Medical Devices and Anticoagulation Side Effects
Penalty
Summary
Two deficiencies were identified involving the failure to provide appropriate treatment and care according to physician orders, resident preferences, and goals. In the first case, a resident with a complex medical history, including pleural effusion, acute respiratory distress, metastatic ovarian cancer, and a recently placed Pleurx chest tube and PICC line, was admitted to the facility. Despite clear hospital discharge instructions for daily drainage and care of the chest tube, there were no physician orders entered for the care of the chest tube or PICC line. Additionally, no baseline care plan was developed for these devices. Multiple staff interviews revealed confusion and lack of clarity regarding who was responsible for entering such orders and developing care plans, with staff indicating that orders for the chest tube and PICC line were not transcribed and that the process for entering non-medication orders was not consistently followed. In the second case, another resident with diagnoses including permanent atrial fibrillation and on anticoagulation therapy experienced nine documented bowel movements that were either bright red or tarry black in color, as recorded by CNA staff. These findings were not documented in nursing progress notes, nor was the physician notified, despite the resident's care plan specifically requiring monitoring for bleeding and immediate physician notification of side effects related to blood thinners. Interviews with nursing staff revealed that CNAs reported the findings to nurses, but the information was not assessed or escalated. Further, nursing and supervisory staff stated that they did not routinely review CNA documentation for such changes, and the advanced practice nurse prescriber was not made aware of the repeated abnormal findings. The facility's own policy required that changes in a resident's condition or treatment be immediately communicated to the resident, their representative, and the attending physician, with documentation of the notification and any new orders in the medical record. In both cases, the facility failed to follow its policy and professional standards of practice, resulting in a lack of appropriate assessment, documentation, and physician notification for significant changes in condition and care needs.
Failure to Provide Proper Hearing Services and Devices
Penalty
Summary
The facility failed to ensure that residents with hearing impairments received proper treatment and assistive devices, including timely audiology consultations and consistent use of hearing aids or alternative communication devices. For one resident with a diagnosis of unspecified hearing loss and moderately impaired cognition, staff were observed not using communication devices, and there was no evidence of an audiology consult in the resident's electronic health record. The care plan included approaches such as exploring technology and providing assistance with communication devices, but these were not implemented. Staff communicated by speaking loudly in the resident's ear, and the resident did not have hearing aids or other hearing devices available. The resident had previously misplaced hearing aids and did not want staff assistance in locating them, and staff were unaware of the last time the hearing aids were used. Another resident with cognitive communication deficits and Alzheimer's disease was observed multiple times without hearing aids, despite a physician's order and care plan directing daily placement of hearing aids. The medication administration record indicated that the task was signed as completed, but direct observation and staff interviews revealed that the hearing aids were not in use and staff were largely unaware of the resident's need for hearing aids. Several staff members, including CNAs, LPNs, and other personnel, did not know whether the resident had hearing aids or where to find information about them, even though this information was documented in the care plan, physician's orders, and assignment sheets. The resident was also observed to have difficulty communicating, and staff often resorted to raising their voices rather than ensuring the use of hearing appliances or alternative devices like a pocket talker. The lack of staff awareness and failure to follow documented care plans and physician's orders resulted in residents not having access to necessary hearing devices, which impeded their ability to communicate and interact with their environment in a comfortable and dignified manner. The deficiency was further evidenced by staff not utilizing available communication aids, not being familiar with residents' needs as documented, and not ensuring that hearing aids were in place as required.
Failure to Provide Range of Motion Exercises as Outlined in Care Plan
Penalty
Summary
A deficiency was identified when a resident with significant medical conditions, including chronic respiratory failure, quadriplegia, and dependence on a ventilator, did not receive appropriate range of motion (ROM) exercises as outlined in their care plan. The resident was assessed as having upper and lower extremity impairments on both sides and was dependent for all activities of daily living. The care plan and CNA care card both specified that staff should assist the resident with upper and lower body ROM exercises during personal care and encourage participation as able. During two separate personal care observations, surveyors noted that staff performed hygiene and positioning tasks but did not carry out or offer ROM exercises to the resident, nor did they ask the resident about performing ROM. Staff were observed washing, repositioning, and dressing the resident, but there was no evidence of joint movement exercises being performed as required by the care plan. The resident confirmed that staff did not ask about or perform ROM during care. Interviews with staff revealed uncertainty regarding the specific expectations for ROM exercises, including the number of repetitions and which residents required them. While staff acknowledged that ROM instructions would be found on care cards, they were either unsure of the details or deferred to therapy or nursing leadership for clarification. The lack of ROM provision was directly observed and confirmed through staff and resident interviews, indicating a failure to follow the established care plan and facility policy for maintaining or improving the resident's range of motion.
Incorrect Transcription and Administration of B12 Injection
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of Vitamin B Deficient Anemia due to Intrinsic Factor Deficiency did not have the correct order for her B12 injection transcribed in the facility records. The resident, who was fully alert and able to make her own care decisions, had been receiving daily injections of methylcobalamin (Vitamin B12) 20 mg/ml, 1 ml daily (20,000 mcg), which she stored in her room and obtained herself because she found the facility pharmacy too expensive. The nurses had been administering this medication daily for several months using the medication the resident provided. However, the physician's order on file and the Medication Administration Records (MAR) documented a different medication and dosage: cyanocobalamin (vitamin B-12) 1,000 mcg daily. This discrepancy between the medication administered and the physician's order was not identified or corrected until the survey, and no explanation was provided for the incorrect transcription of the medication order. The issue was confirmed through observation, record review, and interviews with facility staff.
Medication Error Rate Exceeds 5% Due to Incorrect Preparation and Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as required, with three medication errors identified out of 35 opportunities, resulting in an error rate of 8.57%. One error involved a resident who was administered Sodium Chloride in crushed form through a G-tube, despite staff uncertainty about whether this medication should be crushed or dissolved in water. The LPN responsible for the medication pass prepared and administered the medication in a manner inconsistent with proper protocol, as confirmed by the RN Supervisor who indicated the medication should likely have been dissolved. Two additional errors were observed during the medication administration for another resident. The RN administered only 2,000 units of vitamin D instead of the ordered 10,000 units, and provided a multivitamin with minerals that did not match the physician's order for an adult multivitamin containing specific components such as vitamin K and iron. The discrepancies were confirmed through review of the physician's orders and the medication bottles, and staff interviews revealed a lack of clarity regarding the correct medications to be administered.
Failure to Maintain Required Hospice Documentation and Communication
Penalty
Summary
The facility failed to ensure that the required hospice communication process and documentation were followed for one resident receiving hospice services. According to the contract between the facility and the hospice provider, both parties are responsible for maintaining and sharing pertinent medical records and communication notes, with documentation to be included in the resident's medical record. However, upon review, the surveyor found that hospice progress notes and documentation were not present in the resident's medical record or hospice binder, and staff were unclear about the process for obtaining and maintaining these records. The resident in question had multiple diagnoses, including cerebrovascular disease, vascular dementia, schizoaffective disorder, and mild cognitive impairment, and was assessed as needing total assistance for all activities of daily living. The resident had been admitted to hospice care, but there was no evidence of hospice progress notes or communication in the medical record for several months. Staff interviews revealed inconsistent practices and a lack of clarity regarding who was responsible for collecting and filing hospice documentation, with some staff unaware of where hospice notes should be kept or how to access them. Further interviews with nursing, social work, and medical records staff indicated that hospice documentation was not routinely provided or collected, and that communication between the facility and hospice was often verbal and not consistently documented. The director of nursing and other staff acknowledged that documentation of hospice visits was not always completed unless there were changes or concerns, and that hospice notes were not always made available to the facility. As a result, the required hospice documentation and communication were not maintained in the resident's medical record as stipulated by the facility's contract with the hospice provider.
Failure to Implement Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations, interviews, and record reviews involving two residents. For one resident with a Foley catheter and a physician's order for Enhanced Barrier Precautions (EBP), there was no EBP signage or personal protective equipment (PPE) available outside the room, and staff were unaware of the resident's need for EBP. Multiple staff members, including LPNs, RNs, and CNAs, were either unsure if the resident had a catheter or did not know the required precautions. Staff were observed entering and exiting the resident's room without performing required hand hygiene, and there was no evidence that EBP protocols were being followed during the survey period. Another resident, who had both a Foley catheter and a PEG tube, was placed on EBP, but staff did not consistently adhere to EBP protocols during high-contact care activities. During observed care, CNAs failed to wear gowns while performing dressing, incontinence care, and transfers, despite the presence of EBP signage and PPE outside the room. Additionally, hand hygiene was inconsistently performed, and equipment such as a mechanical lift was not disinfected between uses. The resident's care plan did not document the need for EBP related to the presence of a Foley catheter and PEG tube, despite physician orders. The facility's own infection control policy requires the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, such as Foley catheters and PEG tubes, regardless of MDRO colonization status. However, staff interviews and direct observations revealed a lack of knowledge and inconsistent implementation of these precautions. The failure to follow established protocols and physician orders for EBP was evident in both the lack of appropriate signage and PPE, as well as in the actions of staff during resident care.
Failure to Ensure Competent Respiratory Care for Ventilator and Tracheostomy Residents
Penalty
Summary
The facility failed to provide necessary and appropriate respiratory therapy services consistent with professional standards of practice for residents requiring ventilator and tracheostomy care. Surveyors found that staff were not consistently trained, knowledgeable, or competent to provide respiratory care to residents who were ventilator dependent or had tracheostomies. On multiple occasions, there was no respiratory therapist (RT) present in the facility, and nursing staff, including LPNs and agency nurses, lacked the competencies or confidence to perform essential respiratory tasks such as suctioning, trach care, and ventilator management. In one instance, a resident was not placed on their ventilator at night due to the absence of an RT, and there were no respiratory orders or documented respiratory assessments for that resident over a period of nearly a month. Another resident's family member had to perform critical respiratory care tasks, including hooking up a trach mask to oxygen and providing suctioning, because scheduled staff did not have the necessary knowledge or competencies. Interviews with staff revealed that many were not comfortable or authorized to perform ventilator-related tasks, and some had not received ventilator training. The facility's policies and procedures did not clearly delineate responsibilities between nursing and respiratory therapy staff, nor did they provide for adequate delegation or supervision, especially when LPNs were assigned to complex respiratory care without direct RN oversight. The facility's staffing schedules showed multiple shifts without an RT present, and the facility relied on a small number of LPNs who had attended a ventilator certification course. However, even those who attended the course reported not feeling comfortable or authorized to manage ventilators. There was no evidence of comprehensive competency checks or direct RN supervision for LPNs providing care to ventilator-dependent residents. The lack of clear delegation, supervision, and staff competency created a situation of immediate jeopardy for residents requiring specialized respiratory care.
Failure to Assess, Communicate, and Report Change in Respiratory Status for Ventilator-Dependent Resident
Penalty
Summary
A resident with a history of chronic respiratory failure, chronic kidney disease, congestive heart failure, and other comorbidities, who was ventilator-dependent, experienced a new onset of shortness of breath during the night shift. The respiratory therapist (RT) on duty documented the new symptom and increased the resident's oxygen flow from 5 to 8 liters per minute. However, there was no evidence of a comprehensive assessment to determine the cause of the shortness of breath, nor was there documentation of whether the intervention improved the resident's symptoms. The RT did not communicate this change in condition to the registered nurse on the same shift, to the staff on the following shift, or to the resident's physician for further consultation and treatment. The facility's policies required immediate notification of significant changes in a resident's condition to the physician and resident representative, as well as thorough documentation and assessment. Despite these requirements, no SBAR (Situation, Background, Assessment, Recommendation) was completed, and the change in the resident's respiratory status was not reported or followed up. Nursing staff did not perform or document any further assessments during the shift, and there was no indication that the resident was monitored for response to the increased oxygen or for further deterioration. The resident was later found deceased in the facility, with evidence suggesting they had been deceased for several hours before being discovered. Interviews with staff revealed discrepancies in the documentation and communication regarding the resident's condition and care. Several respiratory therapists and nursing staff confirmed that an increase in oxygen flow should be considered a change in condition requiring assessment and communication. The lack of follow-up assessment, failure to notify the physician, and inadequate communication among staff contributed to the deficient practice, which resulted in a finding of immediate jeopardy.
Removal Plan
- The Director of Nurses along with a consulting respiratory therapist will provide education to all nurses and RT's who will be delegated to the respiratory unit related to recognition of all respiratory changes of condition to include policies and procedures related to same and or other physiological changes of condition.
- Education included staffing expectations for all shifts related to the respiratory unit, change of condition policy and procedures titled: Physician Notification, respiratory policy and procedures including Mechanical Ventilation: Set up and Monitoring, Oxygen Administration, Pulse Oximetry, Tracheostomy Care, notification and documentation expectations with change of condition, where to look for a comprehensive list of orders and treatment within the EHR, shift to shift report expectations and use of 24 hour report board.
- Competency exercises will include a return demonstration on care for a resident with a ventilator and or other open airway that includes verbal affirmation of what, when and whom to report any changes in condition.
- Nursing and respiratory staff will collaborate and communicate any change in condition as a team, implementing appropriate interventions as ordered by provider.
- Signs were posted at the clinical hub on the vent unit to inform clinical staff that if they have not received the competency, they are not permitted to work on the unit until they've received the training.
- All nurses and RT's will be required to view the in-service prior to their next working shift. Once present for their scheduled shift a competency will be provided by a DON or a verified competent facility designee.
- A competent RN will be designated to respond to all emergency situations for ventilator and tracheostomy residents at all times. The RN will be delegated and present and available to ensure timely and comprehensive assessments to any resident demonstrating a potential change in condition.
- The unit will be staffed with an RN who has demonstrated competency in caring for ventilator residents.
- CNAs will be scheduled to meet residents, and RT's scheduled as necessary.
- The Change of Condition policy, Physician Notification has been reviewed and modified to include: Examples of Change of Condition, notification expectations with change of condition, documentation of a change of condition, vital sign expectations.
- All changes in condition will be listed on the 24-hour report board.
- Facility standard of practice policies from [NAME] have all been reviewed, and implemented to include: Mechanical Ventilation: Set up and Monitoring, Oxygen Administration, Pulse Oximetry, Tracheostomy Care.
- Shift to shift report expectations protocol has been developed to use with 24 hour report board.
- Medical Director-EE consulted during the development of this corrective action plan.
- The DON and or designee will review progress notes and 24-hour report board for any changes of condition to ensure all condition changes have been recognized and appropriate for the residents status. An audit tool has been developed to support identification of any condition change. Audits will be conducted with ad hoc training provided as necessary for any missed opportunities.
- The DON and or designee will observe the delivery of respiratory care assigned by nurse or RT.
- All audits will be brought to the Quality Improvement Committee for review and recommendations.
Failure to Provide Written Notice and Choice in Room Changes for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to honor residents' rights to receive written notice and be offered a choice regarding room changes for four ventilator-dependent residents. The facility implemented a reorganization plan that involved relocating all ventilator and tracheostomy residents to different units. A general letter was sent to residents and families outlining the plan, but it did not provide individualized information about available rooms or solicit resident or family preferences. Twenty residents were affected by the move, with some being transferred from private rooms to shared rooms, and the changes were made primarily for facility convenience and staffing efficiency. For the four residents reviewed, there was no documentation that they were given advance notice of their specific room changes or offered a choice of rooms. One resident was not informed of the move or the reason for it and did not receive the facility's letter. Another resident was told about a specific room assignment, but was ultimately moved to a different room without prior notification or choice. A third resident's family was initially told about a room change, but the resident was hospitalized at the time of the move and was placed in a different room upon return, with the family only notified after the fact. The fourth resident's POA was informed of a planned room change, but the resident was moved to a different room than agreed upon, and the POA was unaware of the actual room assignment until contacted by the surveyor. Interviews with staff confirmed that the moves were conducted for operational reasons, such as consolidating ventilator residents for staffing purposes, and that residents and families were not given options regarding room selection. The facility's communication was limited to a general letter and some phone calls, but did not meet the requirement to provide written, individualized notice or to take resident preferences into account prior to making room changes.
Failure to Honor Residents' Right to Refuse Non-Requested Room Transfers
Penalty
Summary
The facility failed to honor residents' rights to refuse non-requested room transfers when the moves were conducted for staff convenience. A reorganization plan was implemented, resulting in the relocation of ventilator-dependent and tracheostomy patients to different units and rooms. The facility sent a letter to residents and families outlining the plan, but the letter did not inform them of their right to refuse the room changes. Interviews and record reviews revealed that residents and their representatives were not given the option to refuse the transfers, and in some cases, were not even notified of the specific room changes until after they occurred. Four residents were specifically reviewed for this deficiency. One ventilator-dependent resident, who was responsible for their own decisions, was moved without prior notification or the opportunity to refuse, and only learned of the move after it happened. Another ventilator-dependent resident was informed of an impending room change and received a letter, but was ultimately moved to a different room than discussed, again without the option to refuse. A third resident, with an activated POA, was moved to a different room upon readmission from the hospital, and the POA was not notified until two days after the move. The fourth resident, also with an activated POA, was moved to a room different from what was communicated, and the POA was not given the option to refuse the move, expressing a preference that the resident not be moved due to familiarity with the previous room and staff. Staff interviews confirmed that the moves were made for the convenience of staffing and unit organization, particularly to consolidate ventilator-dependent residents for easier management by the respiratory therapist. The social worker acknowledged that residents were not given the option to refuse the moves, despite knowing that such a right exists. The administrator and DON were informed by the surveyor that the communication to residents and families did not include information about the right to refuse room changes, and that several residents and representatives were unaware of or not given a choice regarding the transfers.
Failure to Honor Resident Choice in Room Changes During Facility Reorganization
Penalty
Summary
The facility failed to honor and facilitate resident self-determination and choice regarding room changes for four ventilator-dependent residents. The facility implemented a reorganization plan that involved relocating all ventilator and tracheostomy residents to different units and rooms. Communication to residents and families was conducted via a general letter that did not provide individualized information or offer residents or their representatives the opportunity to select or express preferences for available rooms. The moves were carried out for the operational benefit of the facility, specifically to consolidate ventilator residents for staffing convenience, without individualized consideration of resident choice. For the residents reviewed, documentation and interviews revealed that they were either not informed in advance, not given a choice of rooms, or were moved to rooms different from those previously discussed with them or their representatives. One resident was not aware of the move or the reason for it and did not receive the facility's letter. Another resident was told about a specific room change but was ultimately moved to a different room without prior notice or choice. In cases where residents had activated Powers of Attorney, the representatives were either not given options or were notified of the actual room assignment only after the move had occurred, sometimes days later. Staff interviews confirmed that the moves were organized for staff convenience and that no families were present during the moves. The social worker acknowledged that residents were expected to move based on their ventilator status and that all rooms on the new unit were private and remodeled, but did not indicate that any choices were offered. The facility's leadership confirmed that a general letter was sent out but did not address the lack of individualized communication or options for room selection. The surveyor's findings consistently showed that resident preference was not solicited or honored in the room change process.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident with complex medical needs, including acute on chronic respiratory failure, quadriplegia, legal blindness, and non-verbal status. The incident was reported when the resident was sent to the hospital and arrived wet, requiring hospital staff to clean and change the resident, and was also sent without hearing aids or glasses. The facility's initial investigation only included statements from first shift staff and resident interviews, omitting interviews with night shift staff who were responsible for the resident prior to the hospital transfer. The investigation did not establish when the resident was last checked or changed before being sent to the hospital. During the survey, it was revealed that night shift staff were not interviewed as part of the facility's investigation, and there was no documentation of when the resident was last checked or changed. A CNA from the night shift later provided a statement, after prompting from the surveyor, indicating the last time the resident was repositioned. However, this information was not obtained during the facility's initial investigation. The lack of timely and comprehensive staff interviews and failure to determine the resident's care status prior to transfer led to the finding that the investigation into the neglect allegation was incomplete.
Failure to Revise Care Plan After Family Suctioning and Policy Change on Camera Use
Penalty
Summary
The facility failed to revise and update the care plan for a resident with complex medical needs after significant changes and events were observed. The resident, who had severe cognitive impairment, was non-verbal, and required extensive assistance for all activities of daily living, was dependent on a tracheostomy and gastrostomy tube. Despite the care plan including caregiver training for the family in areas such as suctioning, staff observed the resident's family performing suctioning without staff supervision or assistance on multiple occasions. Documentation showed that the family was educated not to perform suctioning without staff present, but the care plan was not updated to reflect these events or provide clear direction to staff regarding education and interventions if the family continued this practice. Additionally, the resident's care plan and CNA care card indicated the use of a camera device in the room to facilitate communication with family, as previously requested by the family. However, the facility implemented a new policy prohibiting cameras in resident rooms due to privacy concerns, and the family was instructed to remove the device. Despite this policy change and the removal of the camera, the care plan and CNA care card were not updated to reflect the discontinuation of the device or the new policy requirements. Interviews with staff, including the DON and Administrator, confirmed that the care plan should have been revised to address both the family’s unsupervised suctioning and the removal of the camera device. The lack of timely updates to the care plan resulted in staff not having current guidance on how to respond to these changes or what education had been provided to the family, as well as inaccurate documentation regarding the resident’s communication methods.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow proper infection control procedures during incontinence care for one resident. During an observation, a CNA was seen providing incontinence care to a resident with a history of recurrent urinary tract infections and multidrug-resistant organism precautions. The CNA cleaned the resident's bowel movement, discarded the soiled washcloths, and then proceeded to clean the resident's vaginal area without removing contaminated gloves or performing hand hygiene between tasks. The resident involved was dependent on staff for toileting hygiene, always incontinent of bowel and bladder, and had a care plan that included enhanced barrier precautions due to a history of frequent UTIs and MDRO. The facility's hand hygiene policy required hand hygiene to be performed routinely and thoroughly, especially when hands are contaminated with body fluids. The observed failure to change gloves and perform hand hygiene between cleaning different areas constituted a breach of the facility's infection control policy.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a change in the resident's condition and the need to alter treatment. On November 11, 2024, a resident, who is non-verbal and has multiple complex medical conditions including quadriplegia and anoxic brain injury, vomited in the morning. A KUB (kidney, ureter, bladder) was ordered by the Nurse Practitioner following the incident. However, the resident's representative was not informed of the vomiting or the subsequent medical order, despite the facility's policy requiring immediate notification of changes in a resident's condition to the resident and/or their representative. The deficiency was identified during a surveyor's visit when the resident's representative expressed that they had not been informed of the incident. The RN Supervisor acknowledged the oversight, admitting that the staff had intended to notify the representative but failed to do so. The Director of Nursing and the Nursing Home Administrator were later informed of the situation. The facility's failure to communicate the change in condition and treatment order to the resident's representative was a clear deviation from their established policy.
Inadequate Grievance Investigation and Documentation
Penalty
Summary
The facility failed to ensure that grievances filed by two residents, R1 and R5, were properly investigated and resolved according to their grievance policy. R5, who was cognitively intact, filed a grievance regarding discomfort with an air mattress, an incident involving a CNA bending her leg during a transfer, and CNAs not setting up her meals. The facility's documentation lacked a thorough investigation, including interviews with R5 or staff, and there was no follow-up to confirm if the grievances were resolved. Additionally, there was no written response provided to R5, and her medical record did not include an assessment of her knee following the incident. R1, also cognitively intact, filed two grievances. The first grievance involved a 45-minute wait for assistance after activating the call light, resulting in soiling herself. The facility's investigation was incomplete, as the call light system was not operational, and no alternative investigation methods were employed, such as interviewing staff or other residents. The second grievance involved a CNA leaving R1's room without completing dressing, raising concerns about privacy and call light response times. Again, the facility's investigation was inadequate, with missing documentation and no interviews conducted with involved staff or other residents. The facility's grievance forms were incomplete, lacking documentation of corrective actions or written responses to the residents. The facility's failure to thoroughly investigate and document the grievances, as well as the lack of communication with the residents, highlights deficiencies in their grievance handling process. The surveyor noted these concerns and shared them with the Nursing Home Administrator, who acknowledged the issues but provided no further information.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report three separate allegations of abuse involving three residents to the State Survey Agency in a timely manner. The first incident involved a resident who reported overhearing a CNA being verbally abusive to another resident. The night nursing supervisor was informed but did not report the incident to the Nursing Home Administrator or the State Survey Agency, as required by the facility's policy. The supervisor dismissed the allegation without conducting a thorough investigation or speaking to the alleged victim. In the second incident, the Nursing Home Administrator received a letter from a resident's representative alleging abuse and neglect. The representative reported that her son was left soiled and unattended, which she considered neglect. Despite receiving this written allegation, the administrator did not report it to the State Survey Agency within the required timeframe, citing a need to gather more information before reporting. The third incident involved a resident's family member being verbally aggressive towards the resident. Staff members witnessed the verbal abuse and reported it to the social worker and nursing supervisor. However, the facility did not report these allegations to the State Survey Agency. The social worker contacted Adult Protective Services, but no further action was taken to report the incident as required by the facility's policy.
Failure to Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of verbal abuse involving two residents. In the first case, a resident's family member was reported to have been verbally aggressive towards the resident on multiple occasions. Despite staff witnessing and reporting these incidents, the facility did not complete a comprehensive investigation. The social worker contacted Adult Protective Services (APS) but did not document the exact date and time of the call, and no interventions were put in place after the incidents were reported. The facility's Director of Nursing and Nursing Home Administrator were aware of the concerns but did not ensure a grievance was completed or that a thorough investigation was conducted. In the second case, a resident reported overhearing a Certified Nursing Assistant (CNA) being verbally abusive to another resident. The night nursing supervisor was informed but did not conduct a thorough investigation, failing to interview the involved residents or obtain staff statements. The Director of Nursing was informed of the allegation but did not ensure that a complete investigation was conducted. The Nursing Home Administrator was unaware of the allegation and stated that an investigation should have been completed if the allegation involved abuse. The facility's failure to investigate these allegations thoroughly was noted by the surveyor, who found no documentation of staff statements or resident interviews. The facility did not submit a thorough investigation to the State Survey Agency, and conflicting information was provided regarding the actions taken in response to the allegations. The lack of a comprehensive investigation into these allegations of verbal abuse represents a deficiency in the facility's adherence to its policies and procedures for handling such incidents.
Lack of Physician Order for Protective Dressing
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. A resident with multiple complex medical conditions, including quadriplegia and legal blindness, was observed with a foam dressing on his mid-back that was dated eight days prior. There was no physician order for this dressing, which was intended for protection. The dressing was applied without proper documentation or orders, and the nursing staff was unaware of the need for a physician order for protective dressings. The deficiency was identified when a surveyor observed the dressing during an incontinence care session. Upon further investigation, it was revealed that the dressing was applied due to the family's anxiety about a previously resolved wound reopening. The Director of Nursing later explained that an order for protection had existed before the resident's hospital visit, but it was not reinstated upon the resident's return. The nurse who applied the dressing did so without verifying the presence of an order, aiming to avoid confrontation with the family.
Failure to Maintain Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a safe environment for a resident, identified as R4, who was admitted to the ventilator wing with chronic respiratory failure and Guillain-Barre Syndrome. On two separate occasions, the heating and air conditioning condensation valance in R4's room fell open, causing condensate and debris to splash onto R4's bed. The first incident occurred on July 10, 2024, and the second on August 8, 2024. Despite the facility's policy requiring regular inspections and maintenance of equipment, the valance was not adequately secured or maintained, leading to these hazardous incidents. Interviews with staff members, including CNAs and a respiratory therapist, revealed that the incidents were reported to supervisors immediately, and maintenance was called to address the issue. However, there was no evidence of a thorough investigation or root cause analysis following the first incident to prevent recurrence. The Director of Building and Grounds indicated that clamps were initially used to secure the valance, but screws were added after the second incident, despite concerns that this might cause more damage if the valance was hit again. The facility's documentation and maintenance logs were inconsistent, with the Director of Building and Grounds admitting that inspections and cleanings were not conducted as frequently as claimed. The Nursing Home Administrator, who started after the first incident, was aware of the second incident and called an ad hoc quality assurance meeting. However, there was no documentation of a follow-up plan or investigation for the first incident, and the facility was unable to provide complete records of maintenance actions taken in response to the incidents.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, specifically in the management of controlled substances and the availability of necessary medications. For one resident, there was a lack of proper documentation and accountability for controlled medication administration. The facility's policy required that controlled substances be documented on an individual record, but the necessary narcotic count sheets were missing, and it was indicated that they might have been sent home with the resident upon discharge, contrary to standard procedure. Another resident did not receive their prescribed medication, Mexiletine, for several scheduled doses due to the medication not being available. Despite attempts to reorder the medication from the pharmacy, it was not delivered in a timely manner, and there was confusion among the staff regarding the reordering process. The facility's staff, including the RN Supervisor and DON, were not fully aware of the situation or the contingency plan for the medication, leading to a lapse in the resident's treatment. The deficiencies highlight a breakdown in the facility's medication management system, including the failure to maintain accurate drug records and ensure the timely availability of medications. The lack of proper documentation and communication among staff members contributed to these issues, affecting the residents' care and treatment.
Medication Errors Result in 16% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate due to four medication errors out of 25 opportunities. The errors involved three residents, identified as R9, R10, and R11. For R9, the errors included not administering the correct medication, Sennosides 8.6 mg-docusate sodium 50 mg, and adding only 20 cc of water to Polyethylene Glycol 3350 17 grams instead of the required 4 to 8 ounces. These actions were observed by a surveyor during medication administration by LPN-X. R10 experienced a medication error when LPN-W added only 30 cc of water to Polyethylene Glycol 3350 17 grams, contrary to the physician's order which required 4 to 8 ounces of water. This discrepancy was confirmed by RN Supervisor-Q, who stated that the correct amount of water should be between 4 to 8 ounces. The surveyor noted this error during the medication administration process. R11's medication error involved the administration of chewable Aspirin 81 mg instead of the prescribed delayed-release Aspirin 81 mg. LPN-V acknowledged the error after being questioned by the surveyor and confirmed that the correct medication was not available in the medication cart. These errors were communicated to the Director of Nursing, Quality and Clinical Support Nurse, and the Nursing Home Administrator on the same day.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) for two residents, R3 and R10. R3, who has multiple complex medical conditions including a tracheostomy and gastrostomy, was observed on two occasions where staff did not wear gowns while providing incontinence care and changing a dressing, despite the presence of an EBP sign and physician orders indicating the need for such precautions. The Infection Preventionist confirmed that staff are required to wear gowns and gloves during high-contact activities, but this protocol was not followed. Similarly, for R10, who has a feeding tube, the surveyor observed that an LPN did not wear a gown while administering medication via the feeding tube, even though an EBP sign was posted indicating the need for gown and glove use. The LPN was unaware of the requirement, indicating a lack of understanding or communication regarding the EBP protocols. The Infection Preventionist reiterated the necessity of wearing appropriate PPE during high-contact care activities, which was not adhered to in this instance. These observations were communicated to the Director of Nursing, Quality and Clinical Support Nurse, and the Nursing Home Administrator. The failure to follow EBP protocols for residents with wounds and indwelling medical devices, as outlined in the facility's infection control policy, highlights a significant deficiency in the facility's infection prevention and control practices.
Inadequate Infection Control Measures for Resident with Parainfluenza
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, leading to the improper management of a resident (R3) with a parainfluenza infection. Observations revealed that the transmission-based precaution sign on R3's door was incorrect, and staff were seen interacting with R3 without wearing masks, even when R3 was coughing. Additionally, R3 was observed in the hallway unattended, coughing, and grabbing hand railings without wearing a mask. Staff also failed to perform hand hygiene between assisting R3 and other residents, and were generally unaware of R3's proper transmission-based precaution status. R3, who has a medical history of falls, dementia, anxiety, depression, wandering, and amnesia, tested positive for parainfluenza. Despite this, R3 was not properly isolated, and the facility's infection preventionist and nursing staff did not ensure that appropriate precautions were in place. The facility's policy required contact plus standard isolation precautions for parainfluenza, but these were not consistently implemented or communicated to the staff. The infection preventionist admitted to not recalling if they had placed the transmission-based precaution sign on R3's door. Throughout the survey, multiple staff members, including LPNs, CNAs, and a chaplain, were observed not adhering to infection control protocols, such as wearing masks and performing hand hygiene. The facility's failure to properly manage R3's infection and ensure staff compliance with infection control measures had the potential to affect 31 residents on the affected unit. The surveyor's findings highlighted significant lapses in the facility's infection prevention and control practices, which were not addressed until after the surveyor raised concerns.
Failure to Complete PASRR Level II Screen
Penalty
Summary
The facility failed to ensure that the PASRR (Pre-Admission Screen and Resident Review) process was conducted accurately for a resident (R2) with a serious mental illness. R2's Level 1 PASRR Screen, dated 12/8/20, indicated a serious mental illness and a 30-day exemption was checked. However, the facility did not initiate a new PASRR Level 1 Screen after the 30-day exemption period, which would have generated a Level II Screen. This oversight was identified during a survey, revealing that the facility did not comply with federal regulations requiring a Level II Screen for residents with serious mental illness or developmental disabilities who stay beyond the 30-day exemption period. R2 was admitted with multiple diagnoses, including Major Depressive Disorder, Anxiety Disorder, and Chronic Pulmonary Disease. The resident's care plan included various interventions for managing mood and behavior, such as administering antidepressant medication, monitoring behaviors, and providing one-on-one support. Despite these measures, the facility failed to follow through with the necessary PASRR Level II Screen, which is crucial for determining the need for specialized services and appropriate nursing facility placement. Interviews with facility staff, including the Director of Admissions, Lead Social Worker, and Social Worker, revealed a lack of clarity and responsibility regarding the PASRR process. The Director of Admissions stated that social services were responsible for follow-up if a resident stayed past 30 days, but social services staff indicated they had never been involved in completing PASRR Screens. This lack of a clear process and responsible party led to the failure to update R2's PASRR Level 1 Screen and complete the required Level II Screen, resulting in non-compliance with federal regulations.
Failure to Ensure Timely GI Consult for Resident
Penalty
Summary
The facility failed to ensure that a resident (R2) received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. R2 was admitted with multiple diagnoses, including Major Depressive Disorder, Chronic Pulmonary Disease, and Chronic Kidney Disease. The hospital discharge paperwork instructed the facility to follow up with a gastrointestinal (GI) consult scheduled for 3/6/24, but R2 did not attend this appointment until 5/15/24. There was no documentation explaining why R2 missed the initial appointment, and R2 did not recall refusing to go to the consult. The facility's records and interviews with staff revealed that the GI consult was known and scheduled, but the appointment was missed without any documented reason. The Administrative Assistant responsible for setting up appointments confirmed that the transportation and appointment were arranged, but could not explain why R2 did not attend. The Nurse Practitioner and other staff members, including the Social Worker and Licensed Practical Nurse, were unaware of the missed appointment or the reasons behind it. The Director of Nursing and other administrative staff were informed of the deficiency but could not provide additional information. R2 eventually received the GI consult on 5/15/24, which led to further instructions for a CT scan and a referral to a surgeon. The delay in attending the GI consult was acknowledged as unacceptable by the Chief Clinical Officer. The lack of documentation and follow-through on the scheduled appointment indicated a failure to provide care in accordance with the resident's care plan and professional standards of practice.
Dish Machine Temperature Verification Failure
Penalty
Summary
The facility was unaware that the high temperature dish machine was not functioning correctly, which has the potential to affect all 95 residents. During an observation, the temperature gauges on the dish machine did not indicate that the machine was reaching the appropriate sanitizing temperatures. The facility lacked a process to verify the internal temperature of the dish machine, and there was no documentation of the dish machine's temperature for the morning of the observation. The Food Service Manager initially thought the machine was a low temperature dish machine, indicating a lack of awareness about the equipment in use. When the Surveyor asked the Food Service Director about the verification process, it was revealed that test strips were not regularly used in the kitchen, and the conveyor belt of the dish machine was also not working. The Food Service Director had to manually push the dirty bin into the machine and confirmed that the machine was not reaching the required temperatures. The facility's dish machine temperature logs for February were incomplete, lacking employee initials, while the logs for March were correctly completed. The issue was brought to the attention of the Nursing Home Administrator, Director of Nursing, and a Consultant during an end-of-day meeting.
Deficiencies in Water Management and COVID-19 Precautions
Penalty
Summary
The facility does not have a comprehensive water management plan, and the existing plan was outdated and not included in the facility assessment. The water management team listed in the plan were no longer employed at the facility, and there was no flow chart indicating potential areas of concern for the spread of opportunistic pathogens in the facility's water system. The Nursing Home Administrator (NHA) and the Supervisor of Buildings and Grounds (SoB&G) were unsure if a water management team met regularly, and the Infection Preventionist (IP) was not part of a water management committee. Additionally, there was uncertainty about whether routine flushing of unused sinks and toilets was being conducted, especially in a wing with ten closed bedrooms for over a year. The Director of Maintenance (DoM) was on vacation and could not provide further information at the time of the surveyor's request. The facility failed to follow transmission-based precautions for COVID-19. A resident who tested positive for COVID-19 was observed without a mask, and staff entering the resident's room did not wear the appropriate personal protective equipment (PPE). Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) were observed entering the room with only surgical masks, gloves, and sometimes without gowns or eye protection. The CNAs were confused about the required PPE for COVID-19 precautions, and the RN was wearing an N95 mask that had not been fit tested. The Infection Preventionist acknowledged the confusion among staff and stated that the facility follows CDC guidelines, which require gown, gloves, N95, and eye protection for any staff entering a COVID-19 positive room. The facility did not conduct annual fit testing for N95 masks as required by OSHA's Respiratory Protection standard. The RN and CNAs interviewed could not recall when they were last fit tested, and the RN admitted to wearing an N95 mask that had not been fit tested. The Infection Preventionist and Wound Care RN acknowledged the lapse in annual fit testing and mentioned that they had started a project to log fit test dates and had a few different mask models for fit testing. However, this project was not yet fully implemented, leading to staff using N95 masks without proper fit testing.
Failure to Ensure Resident Safety During Abuse Investigation
Penalty
Summary
The facility did not ensure residents were protected from potential abuse while an investigation of an allegation of abuse was being conducted. A resident (R34) alleged that another resident (R100) entered their room, hit them on the head, and twisted their arm. Although R100 was moved to another unit after the incident, there was no increased supervision provided during the investigation, potentially putting other residents at risk. The facility's records indicated that R34's vital signs were stable after the incident, and no signs of injury were found. However, R100, who was confused and had no recollection of the event, was transferred to another floor without any additional monitoring protocols in place. This lack of increased supervision was a significant oversight, especially given R100's history of wandering and needing redirection multiple times during the night shifts following the incident. The facility's Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that no specific interventions were implemented to safeguard the residents on the new unit where R100 was moved. The surveyor's concern was that the other residents were not adequately protected from a potentially abusive situation while the allegation was being investigated.
Failure to Assess and Justify Indwelling Catheter Use and Manage Constipation
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling catheter was assessed for the removal of the catheter as soon as possible, and that the catheter was used only with valid medical justification. The resident, identified as R87, was admitted with a Foley catheter but had no documented diagnosis or medical justification for its use. Additionally, there was no assessment or plan for the removal of the catheter, and the physician's order to change the catheter did not specify the size required. The care plan for R87 also lacked a diagnosis for the catheter and did not include a care plan for constipation, despite the resident's history of significant constipation documented in the hospital discharge summary and the use of medications that could cause constipation, such as Oxycodone. The facility's failure to comprehensively assess and document the resident's bowel and bladder needs contributed to the deficiency. The facility's policy on indwelling urinary catheter care and management emphasizes the importance of using catheters only for appropriate indications and discontinuing them as soon as they are no longer clinically indicated. However, the facility did not follow this policy for R87, who had a Foley catheter without a documented medical justification. The resident's medical record did not include a diagnosis for the catheter, and the facility did not provide evidence of any follow-up to determine the need for the catheter or a plan for its removal. The lack of documentation and assessment for the catheter's necessity and size indicates a failure to adhere to the facility's policy and best practices for catheter care. Furthermore, the facility did not adequately monitor and manage R87's bowel movements, leading to episodes of constipation and fecal impaction. Despite the resident's history of constipation and the use of medications that could exacerbate this condition, the facility did not develop a care plan for constipation or consistently monitor the resident's bowel movements. The resident experienced significant constipation, resulting in a distended abdomen and an emergency room visit for fecal impaction. The facility's progress notes and bowel movement records indicate inconsistent documentation and a lack of timely intervention for constipation. The Director of Nursing acknowledged the need for education and revisions to the bowel movement monitoring program to ensure appropriate interventions based on the size, consistency, and pattern of bowel movements.
Failure to Maintain Accurate Drug Regimens
Penalty
Summary
The facility did not keep two residents free from unnecessary drugs. Resident R401 was prescribed Memantine 5 mg daily for depression, despite not having a diagnosis of depression. The resident's medical records and comprehensive care plan indicated diagnoses of chronic obstructive pulmonary disease, congestive heart failure, muscle weakness, dementia, and pulmonary hypertension, but not depression. The Director of Nursing (DON) confirmed that the resident did not have a diagnosis of depression and clarified that the Memantine was prescribed for dementia, not depression. Resident R33 was prescribed Phenytoin 100 mg three times daily for seizures, although the resident's medical records did not include a diagnosis of seizures. The resident's diagnoses included dementia, palliative care, major depressive disorder, insomnia, anxiety, and muscle weakness. The DON and Nurse Practitioner (NP) confirmed that the resident was receiving Phenytoin for seizures based on previous hospital records, but the facility's records did not reflect this diagnosis. The NP indicated that the resident would have frequent Phenytoin drug lab levels drawn to manage the prescription. The surveyor noted that both residents were receiving medications for conditions not documented in their diagnoses, which constitutes a failure to keep the residents' drug regimens free from unnecessary drugs. The facility's records were not updated to reflect the correct diagnoses, leading to the administration of medications without proper documentation of the conditions they were intended to treat.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility did not ensure that drugs and biologicals were labeled with expiration dates when applicable, were not expired, and were stored under proper temperature controls. During an observation of the SV1 medication room, the surveyor noted that the refrigerator, which contained medications, had a thermometer reading below the recommended temperature range of 36-46 degrees Fahrenheit. Despite the temperature log indicating out-of-range temperatures, no corrective action was taken, and the LPN responsible did not notify anyone about the issue. Additionally, several insulin pens and vials were found open and used but not dated when opened, and expired medications were found in the SV2 back medication cart. The surveyor observed multiple instances of non-compliance with the facility's medication administration policy. Insulin pens and vials belonging to various residents were found open and used without being dated, and several medications were found to be expired. The LPNs involved were either unaware of the proper procedures or failed to follow them, leading to the deficiencies. The facility was informed of these concerns during the daily exit meeting, but no additional information was provided at that time.
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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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