Marquardt Memorial Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Watertown, Wisconsin.
- Location
- 1020 Hill St, Watertown, Wisconsin 53098
- CMS Provider Number
- 525543
- Inspections on file
- 32
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Marquardt Memorial Manor during CMS and state inspections, most recent first.
The facility failed to follow its grievance policy and thoroughly investigate or resolve multiple resident complaints. A resident with paraplegia and pressure injuries had a family member file a written grievance about a missed medical appointment, inadequate wound care supplies, incontinence care issues, and unreturned calls, but the grievance form was left incomplete and no investigation or follow-up occurred. Another resident with post-stroke hemiplegia, dependent on staff for showers, reported going weeks without showers and having a family member report this to the facility, yet no grievance documentation or investigation was found. A third resident with COPD, morbid obesity, PVD, and O2 dependence reported that an RN used profanity during a nighttime medication pass; although the resident told an RN and a CNA, and an LPN reported the concern to a supervisor, the facility did not log a grievance, document the event in the record, or complete an official investigation.
The facility failed to consistently provide scheduled showers/baths and honor bathing preferences for three dependent residents. One resident with hemiplegia and intact cognition had multiple missed weekly showers documented as blank entries on the MAR, and both the resident and a family member reported that showers were not provided as scheduled. A second resident with paraplegia and morbid obesity had orders for weekly skin checks and baths, but did not receive showers because the facility’s bariatric shower chair was nonfunctional and a replacement did not arrive until after discharge, with staff indicating that only bed baths could be given. A third resident with moderate cognitive impairment reported preferring showers but stated staff did not ask about preferences and instead provided bed baths. The DON and an LPN confirmed that MAR/TAR blanks indicate showers/baths were not completed and that refusals and reasons should be documented, showing that ordered bathing care and resident preferences were not consistently followed or recorded.
A resident with paraplegia, obesity, neurogenic bowel and bladder, and a history of sacral pressure injuries had a large unstageable coccyx DTI managed per APNP orders with cleansing, chamosyn cream, and no dressing, along with q2h repositioning and weekly skin checks. Despite this, an LPN independently applied 4 x 4 foam border adhesive dressings to an open buttocks area on multiple occasions without a provider order, while only sending a message to the provider and later finding no corresponding order in the record. Separately, the admission head-to-toe skin assessment by an RN did not identify a penile/scrotal pressure injury, which was later discovered and documented during a subsequent hospital stay, with hospital notes indicating the resident and family were previously unaware of that wound. The DON stated that all skin should be assessed on admission and that foam border dressings should not be used without an order.
A resident with paraplegia, neurogenic bladder, and other comorbidities was admitted with an indwelling urinary catheter that was scheduled to be replaced with a suprapubic catheter. The cognitively intact resident had a procedure appointment, but the facility did not ensure stretcher transport was properly requested and arranged, and only a last-minute phone request was made, which did not result in transport being secured. The facility lacked a written policy for scheduling appointments and transportation, and no electronic request for the original appointment date was found, causing the suprapubic catheter placement to be delayed and the procedure to be rescheduled.
A resident with COPD, morbid obesity, alveolar hypoventilation, history of pulmonary embolism, and dependence on supplemental O2 had an order for 2–4 L via nasal cannula to maintain SpO2 > 90%, with tubing changes as needed. An RN changed the resident’s oxygen tubing but did not turn the oxygen back on, and the resident’s attempts to summon staff using the call light and phone went unanswered. A CNA later found the oxygen off during morning rounds and turned it back on, confirming the resident’s report that the oxygen had been off for most of the night, while the regional nurse consultant was unaware the resident had been without oxygen.
A resident with multiple medical conditions and a history of a revoked POA was not provided with adequate support or opportunity to complete a new POA document, despite being unable to read or write and expressing a desire for assistance. Facility staff were unaware of the resident's illiteracy and did not take further action to fulfill the resident's request for a decision maker, contrary to facility policy and regulatory requirements.
A resident with intact cognition and significant medical needs reported that a CNA repeatedly called them "stupid" in front of other staff. The allegation was communicated to staff, but the social worker and DON were not promptly informed, and the required report to the State Agency was not made in accordance with facility policy.
An LPN and a CNA failed to wear required gowns and did not follow proper hand hygiene or disinfection procedures while providing wound care to a resident with a stage 4 pressure ulcer and indwelling devices. Supplies were placed on unclean surfaces, and the treatment cart and equipment were not properly disinfected before being used for other residents. Staff interviews confirmed lapses in following infection control policies, including PPE use and handling of wound care items.
Two residents did not receive adequate supervision or assistance devices to prevent accidents, resulting in one resident sustaining a major injury after a fall when care plan interventions were not followed, and another experiencing repeated falls without appropriate new interventions or root cause analysis. The facility failed to ensure care plans were implemented and did not individualize fall prevention strategies after multiple incidents.
A resident with respiratory symptoms and under droplet precautions had a sign posted requiring hand hygiene and mask use upon room entry. A CNA was observed entering the room twice without a mask or performing hand hygiene. Staff interviews revealed inconsistent understanding of droplet precaution protocols, and the NHA acknowledged that some staff, including managers, may not have followed the required infection control measures.
The facility failed to include necessary details in their assessment to care for residents with Substance Use Disorder (SUD), affecting nine residents with diagnoses such as alcohol abuse and dependence. The assessment did not evaluate the SUD population or address their specific needs, and the facility lacked policies, procedures, and staff training for SUD care. Interviews revealed staff had not received training on SUD care or medication interactions, and the Director of Nursing confirmed the absence of education and competencies for SUD care.
The facility failed to provide necessary behavioral health services for residents with substance use disorders (SUDs). A resident with a history of cocaine, alcohol, and cannabis use was frequently intoxicated, yet no comprehensive care plan or timely interventions were implemented. Another resident consumed significant amounts of alcohol daily without a care plan addressing his use. A third resident, admitted with alcohol use disorder, continued drinking without a care plan in place. The facility's lack of structured care plans for SUDs highlights a significant oversight.
A resident with multiple health issues, including a history of pressure injuries, developed unstageable pressure injuries due to the facility's failure to revise the care plan and monitor skin under a CAM boot. The facility did not conduct timely assessments, leading to the progression of the injuries.
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents. One resident experienced an unwitnessed fall, and their care plan was not updated. Later, they were improperly transferred, resulting in a fracture. Another resident's fall was not thoroughly investigated, with incomplete documentation and unclear supervision. These incidents highlight deficiencies in adherence to fall prevention policies and resident supervision.
The facility failed to maintain sanitary food preparation and service practices, as the dishwashing machine did not reach the required sanitizing temperature, and a cook did not follow proper hand hygiene protocols. The dishwashing machine consistently failed to reach the necessary 180 degrees Fahrenheit for sanitization, yet staff continued to use it. Additionally, a cook was observed handling food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands, violating facility policies. These deficiencies potentially affected all 76 residents.
A facility failed to conduct a comprehensive assessment and develop a plan of care for a resident using an abdominal binder as a physical restraint. The resident, with severe disabilities and a g-tube, had the binder in place at all times without evidence of it being the least restrictive option or documentation of ongoing re-evaluation. The facility lacked a policy on restraint use, and the binder's use was not documented in the resident's care plan.
The facility failed to complete neurological checks following unwitnessed falls for three residents, as per policy. A resident with alcohol-induced dementia had multiple falls, but checks were delayed until a nurse practitioner's order was received. Another resident experienced unwitnessed falls on several occasions, with discrepancies noted between handwritten and electronic records, indicating missed checks. Additionally, a resident at high fall risk due to hemiplegia and dementia had an unwitnessed fall, with significant gaps in the required neurological evaluations.
A facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease by not assessing the resident's AV fistula for adequate blood flow. Despite the facility's policy requiring coordination with the dialysis center, staff did not routinely check the access site, and there was no evidence of documented assessments. The resident reported that staff rarely looked at the site, and the ADON confirmed the lack of consistent monitoring.
A resident's medical record lacked documentation regarding the offering, receipt, or declination of a Pneumococcal immunization, contrary to the facility's policy. The ADON admitted that the resident's immunization status was not addressed upon admission and was not included in the monthly audit. The deficiency was identified during a surveyor's review, highlighting a gap in the facility's immunization documentation process.
A facility failed to document a resident's COVID-19 immunization status, as required by its policy. The resident's electronic medical record lacked information on whether the vaccine was offered, received, or declined. The ADON admitted the oversight, noting that the resident was not included in the monthly immunization audit and had not been offered the vaccine. The facility's admission process for immunizations was still being developed.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to thoroughly investigate and resolve grievances for three cognitively intact residents. For one resident with complete paraplegia, type 2 diabetes, class 3 obesity, neurogenic bowel and bladder, and pressure injuries, a family member submitted a written grievance on 1/7/26 regarding a missed suprapubic catheter placement appointment due to unscheduled transport, worsening of an existing pressure injury and discovery of another pressure injury in the hospital, lack of appropriate wound care supplies, repeated observations of the resident in a soiled brief with stool dripping on the floor, and unreturned phone calls from staff. The grievance form in the facility’s file was incomplete, and the Registered Nurse Consultant confirmed that although the concerns were reported, the facility did not complete an investigation or follow-up on the grievance. Another resident with hemiplegia and hemiparesis following a stroke, who was dependent on staff for showers and had intact cognition, reported filing a grievance in September 2025 about not receiving a shower for three weeks. The resident did not recall anyone following up about the concern and stated that a family member who worked at the facility reported the missing showers to the facility. The family member confirmed reporting that the resident was not receiving showers and that the resident’s showers resumed afterward, but did not recall whether an investigation occurred. When surveyors requested documentation of a grievance related to this issue, facility leadership could not produce any grievance documentation or investigation related to the resident’s shower complaints. A third resident, who had COPD, morbid obesity, peripheral vascular disease, a history of pulmonary embolism, and dependence on supplemental oxygen and staff assistance for most ADLs, reported that on a night in January 2026, an RN attempted to administer medication with a spoon without acknowledging the resident’s ability to self-feed and need for oxygen tubing change. The resident stated that when the RN returned later and again attempted to give medication, the RN said, “I’m not going to take your shit,” then changed the oxygen tubing and left. The resident reported this incident to an RN and a CNA on the following morning shift. Both staff members confirmed the resident’s report and stated they relayed the concern to a nurse or supervisor, and an LPN acknowledged being told the resident believed the RN had sworn at them and reported it to a supervisor. The RN Consultant confirmed the concern was reported but stated the facility did not complete an official investigation or file a grievance, and there was no related progress note in the resident’s record.
Failure to Provide Scheduled Showers and Honor Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers or baths and to honor bathing preferences for three residents who required staff assistance with activities of daily living. One resident with hemiplegia and intact cognition was dependent on staff for showers and was scheduled for a weekly bath on Tuesdays. Review of the Medication Administration Record (MAR) showed multiple Tuesdays over several months with blank documentation for the ordered weekly skin check and bath, and the facility could not produce complete bath schedules for parts of November and December. The resident reported wanting showers, stated they had not received showers on recent scheduled days, and denied refusing showers, while a family member confirmed the resident had complained about not receiving showers, particularly in November and December. Another resident with complete paraplegia, obesity class 3, neurogenic bowel and bladder, and intact cognition had an order for a weekly skin check and bath according to the shower schedule. The Treatment Administration Record (TAR) showed the order documented as completed on three dates, but the facility did not have a functioning bariatric shower chair during the resident’s stay. The scheduler/central supply staff member stated a bariatric shower chair was ordered the day before admission after being informed of the need, that the existing bariatric chair was found to be nonfunctional and could not be repaired by maintenance, and that the replacement chair did not arrive until after the resident was discharged. An RN stated that the resident’s scheduled “shower” would have been provided as a bed bath due to the lack of a working bariatric shower chair. A third resident with moderate cognitive impairment and an activated POA was dependent on staff for bathing and expressed a clear preference for showers over bed baths. The resident reported that staff did not ask about bathing preference and instead provided bed baths, stating they wanted only showers and were bothered by not receiving them. The DON stated that showers and baths are documented on the MAR or TAR, that refusals and reasons should be documented, and that blanks should not be left because they indicate a shower or bath was not completed. The DON and an LPN both indicated that a checked MAR/TAR entry signifies that a shower/bath and skin check were completed, and that blank entries mean the care was not done, confirming that scheduled showers/baths and resident preferences were not consistently honored or documented for these residents.
Failure to Follow Wound Orders and Identify All Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services to prevent pressure injuries from developing and to promote healing of existing wounds for one resident. The facility had a Pressure Injury Prevention and Managing Skin Integrity policy requiring Braden Scale risk assessments, comprehensive skin checks on admission and weekly, identification and care planning of skin breakdown, and collaboration with the IDT and providers for abnormal skin findings. The policy also required weekly wound rounds, provider notification of wound decline, and adherence to ordered interventions. Despite these requirements, the facility did not consistently follow its own policy or ensure that wound treatments were based on provider orders. The resident was admitted with multiple significant conditions, including complete paraplegia, type 2 diabetes, morbid obesity, neurogenic bowel and bladder, and a history of sacral pressure injuries. On admission, an RN documented a stage 2 coccyx pressure injury and coccyx bruising, and later a left gluteal MASD, with subsequent development of an unstageable coccyx deep tissue injury. Wound assessments documented a large sacral/coccyx area with deep purple discoloration and scattered open areas, and an APNP ordered cleansing with soap and water, application of chamosyn cream twice daily, aggressive offloading, and specifically indicated not to cover the wound with a dressing. Facility orders reflected these directions, including repositioning every two hours and weekly skin checks. However, the facility’s documentation did not show any wound orders on the hospital discharge summary at admission, and the facility relied on its own wound team and internal assessments to manage the coccyx wound. An LPN reported that, on a weekend, after noticing what appeared to be an open area on the resident’s buttocks, the LPN applied 4 x 4 foam border adhesive dressings and barrier cream multiple times due to the resident’s frequent loose stools causing dressings to come off. The LPN stated they sent a message to the provider when the open area was noticed but could not locate any provider order in the medical record authorizing the use of foam border dressings during the period they were applied. The DON later stated that staff should not apply foam border dressings without an order and that the provider should have been informed as soon as the wound was identified. Additionally, a separate pressure injury on the resident’s penile/scrotal area was not identified by facility staff during the admission head-to-toe skin assessment and was instead discovered later at the hospital, where documentation indicated the resident and family were not aware of this wound until that hospitalization. The DON confirmed that admission skin assessments should include viewing all skin areas, and the RN who performed the admission assessment stated that if a penile pressure injury had been seen, it would have been documented, indicating that this wound was not identified by the facility prior to the hospital finding it.
Failure to Arrange Timely Transportation for Suprapubic Catheter Placement
Penalty
Summary
The facility failed to ensure timely placement of a suprapubic catheter for one resident when transportation was not secured for a scheduled medical appointment. The resident had multiple diagnoses including complete paraplegia, type 2 diabetes mellitus, anxiety, class 3 obesity, neuromuscular dysfunction of the bladder, and neurogenic bowel, and was admitted with an indwelling urinary catheter that was to be replaced with a suprapubic catheter. The resident was cognitively intact, with a BIMS score of 15, and was their own decision maker. A grievance documented that the resident was scheduled for suprapubic catheter insertion on 12/31/25, but the facility did not ensure stretcher transportation was arranged as requested by a family member, resulting in the need to reschedule the procedure. The surveyor’s review of the medical record and interviews with the Scheduling Coordinator revealed that transportation requests are made through the facility’s electronic medical record system and then processed by the Scheduling Coordinator or a backup staff member. The facility did not have a written policy or procedure for appointments and transportation. Initial review showed no appointment or transportation request entered for the resident’s 12/31/25 procedure. Further review identified only a last-minute call from staff to the Scheduling Coordinator’s coworker requesting stretcher transport for that date, and the facility was unable to secure stretcher transport on short notice. As a result, the resident’s appointment for suprapubic catheter placement had to be rescheduled to 1/5/26.
Failure to Restart Oxygen After Tubing Change
Penalty
Summary
The facility failed to ensure that a resident dependent on supplemental oxygen received ordered oxygen therapy following a tubing change. The resident had multiple respiratory-related diagnoses, including COPD, morbid obesity, alveolar hypoventilation, a history of pulmonary embolism, and was ordered to receive 2–4 L oxygen via nasal cannula to maintain oxygen saturation above 90%, with tubing to be changed and dated every 7 days and as needed. The facility’s Standard Respiratory Protocol directed RNs to apply oxygen as ordered for individuals with impaired or potential impairment of gas exchange. On the night of 1/9/26, an RN changed the resident’s oxygen tubing but did not turn the oxygen back on afterward. Following the tubing change, the resident reported turning on the call light and calling the nurses’ station, but stated that no one answered. The resident, who was cognitively intact and their own decision maker, stated that a CNA discovered in the morning that the oxygen was off and then turned it back on. The CNA confirmed that, upon checking the resident that morning, the oxygen was not on and that the resident reported the RN had changed the tubing without restarting the oxygen, resulting in the resident being without oxygen for most of the night, approximately six hours. The Regional Nurse Consultant stated they were not aware that the resident had gone without oxygen.
Failure to Provide Support for Advance Directive Completion
Penalty
Summary
The facility failed to ensure that a resident was provided with an opportunity to create a Power of Attorney (POA) document or designate an alternate decision maker in the event of incapacity, as required by facility policy and the Patient Self Determination Act. Upon admission, the resident, who had multiple complex medical diagnoses including spina bifida, paraplegia, and a stage 4 pressure ulcer, was not offered adequate support to complete a POA document despite expressing discomfort with making healthcare decisions and being unable to read or write. The resident reported that a previous POA designation had been revoked by Adult Protective Services (APS) and expressed a desire for a new POA or Guardian to assist with decision-making. Staff interviews revealed that the social worker was unaware of the resident's illiteracy and was uncertain about the existence of a current POA document. Attempts to obtain information from APS were unsuccessful, and APS confirmed that the resident was their own decision maker and entitled to complete a new POA if desired. Despite the resident's request and the facility's policy to discuss and verify advanced care planning upon admission and at care conferences, no further action was taken by the facility to assist the resident in completing a new POA document.
Failure to Timely Report Alleged Verbal Abuse to State Agency
Penalty
Summary
An allegation of verbal abuse was made by a resident with intact cognition and multiple medical conditions, including spina bifida, paraplegia, and a stage 4 pressure ulcer. The resident reported to staff that a CNA repeatedly addressed them as "stupid" in the presence of other staff members. The resident informed an unidentified staff member about the name-calling, who stated they would notify the social worker and ensure the CNA did not work with the resident that day. However, the social worker was not made aware of the allegation until later, and the Director of Nursing was also not informed until the day of the surveyor's investigation. The facility's policy requires that all allegations of abuse be reported to the State Agency immediately, or within specific timeframes depending on the severity. Despite this, the allegation was not reported to the State Agency as required. The staff member who initially received the report relayed the information to the Director of Nursing, but there was a delay in both internal and external reporting. The correct CNA was only identified and suspended after the surveyor's involvement, indicating a failure to follow the facility's abuse reporting protocol.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during wound care for a resident with significant medical needs, including a stage 4 pressure ulcer and indwelling medical devices. During the observed wound care procedure, both an LPN and a CNA entered the resident's room without donning gowns, despite signage indicating Enhanced Barrier Precautions (EBP) were required. The LPN brought a treatment cart into the room, placed wound care supplies directly on the bedside table without disinfecting the surface or using a barrier, and both staff members wore only gloves during the procedure. Their clothing came into contact with the resident's environment, including bed linens, increasing the risk of cross-contamination. Throughout the wound care process, the LPN did not consistently perform hand hygiene at required moments, such as after glove removal and before handling clean supplies. The LPN also handled wound care items and the resident's environment with bare hands at times, and placed unused dressing packages and clean gloves on potentially contaminated surfaces. After completing care, the LPN returned the treatment cart to the nurses' station and began disinfecting equipment, but did not observe the required dwell time for the disinfectant before placing items back into the cart, further compromising infection control. Interviews with the LPN, CNA, and Director of Nursing confirmed a lack of adherence to the facility's policies regarding PPE use, hand hygiene, and the handling of wound care supplies. The LPN and CNA acknowledged forgetting to wear gowns, and the LPN was unaware of the proper use of disinfectant products. The Director of Nursing verified that gowns should have been worn, supplies should have been handled with barriers, and items used in the resident's room should not be used for other residents. These failures resulted in a breakdown of the infection prevention and control program as required by facility policy.
Failure to Prevent Accidents and Implement Effective Fall Interventions
Penalty
Summary
The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, resulting in one resident experiencing actual harm. One resident, who had multiple diagnoses including stroke, muscle weakness, and moderate cognitive impairment, was assessed as a moderate fall risk and required two staff for transfers with a Hoyer lift, as well as specific interventions such as keeping the bed against the wall and the call light within reach. Despite these documented interventions, the resident experienced a fall with major injury when a CNA attempted to reposition the resident alone, rolling the resident away from himself, which led to the resident falling to the floor and sustaining a right hip fracture. At the time of surveyor observation, the resident's bed was not against the wall and the call light was on the ground, not within reach, contrary to the care plan requirements. Another resident with diagnoses including dementia and a history of falls experienced twelve falls over a period of time. The care plan included standard fall prevention interventions such as offering toileting every two hours, ensuring the call light was within reach, and not leaving the resident unattended while awake. However, after each fall, the facility either failed to add new interventions to the care plan or only added interventions that were already considered standard practice, such as offering toileting at certain times. The facility did not complete a root cause analysis for any of the falls, including those resulting in injury, and did not implement individualized or effective interventions to address the repeated falls. Interviews with the DON confirmed that root cause analyses were not performed unless there was an injury, and that interventions added after falls were often not new or specific to the resident's needs. The interdisciplinary team reviewed falls in morning meetings, but did not identify or address the lack of new interventions for the resident with repeated falls. The facility's failure to follow care plans, ensure required safety devices were in place, and implement appropriate interventions after falls led to continued risk and actual harm for the residents involved.
Failure to Adhere to Droplet Precaution Protocols for Resident on Isolation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to droplet precaution protocols for a resident who was under isolation. The resident, who had a recent history of respiratory symptoms including cough, nasal congestion, fever, and was being treated for pneumonia and pleural effusion, had a droplet precaution sign posted on the door. The sign instructed all individuals to perform hand hygiene upon entering and exiting the room and to wear a mask when entering. Despite these clear instructions, a Certified Nursing Assistant (CNA) was observed entering the resident's room on two separate occasions without wearing a mask or performing hand hygiene. Interviews with various staff members, including LPNs, CNAs, a Med Tech, the DON, and the Nursing Home Administrator, revealed inconsistent understanding and application of droplet precaution protocols. Some staff believed that precautions were only necessary when providing direct care, while others stated that PPE and hand hygiene were required every time anyone entered the room. The Nursing Home Administrator acknowledged that extra staff, including managers, may have entered the room without following the required precautions, especially during meal delivery. The administrator also noted confusion among staff due to the frequency and variety of precaution signs, which may have contributed to the failure to consistently implement infection control measures as outlined in the facility's policy.
Deficiency in Facility-Wide Assessment for SUD Care
Penalty
Summary
The facility failed to ensure that their facility-wide assessment included all necessary details to provide adequate care for residents with Substance Use Disorder (SUD). This deficiency potentially affects nine residents with SUD diagnoses, including conditions such as alcohol abuse, alcohol dependence, and cannabis use. The facility's assessment did not evaluate the SUD resident population or address their specific physical and behavioral health needs. Additionally, the facility's admission capabilities did not list SUD as a condition they are equipped to manage, and SUD was not included in the resident population characteristics or conditions. The facility lacked policies and procedures for the care of residents with SUD, and there was no education, training, or competencies provided to staff regarding the care of these residents. Interviews with staff, including an LPN and an RN, revealed that they had not received training or completed competencies related to SUD care, including knowledge of medication interactions with alcohol. The Director of Nursing confirmed the absence of education and training for staff on SUD, withdrawal symptoms, or overdoses, and acknowledged that there was no assessment for residents under the influence of substances. The facility's failure to evaluate and address the needs of the SUD resident population, along with the lack of staff training and competencies, indicates a significant oversight in their facility-wide assessment. This deficiency highlights the facility's inability to provide appropriate care and services to residents with SUD, potentially compromising their health and safety.
Failure to Address Substance Use Disorders in Residents
Penalty
Summary
The facility failed to provide necessary behavioral health services to ensure residents received the highest practicable mental and psychosocial well-being, specifically in addressing substance use disorders (SUDs). Three residents, identified as R1, R4, and R5, were not provided with comprehensive assessments or person-centered care plans to address their SUDs. R1, who had a history of cocaine, alcohol, and cannabis use, was frequently intoxicated within the facility, yet no comprehensive care plan or timely interventions were implemented to address his SUD. Despite being aware of R1's alcohol use, the facility delayed implementing monitoring orders and failed to provide timely AODA/mental health referrals. R5, who regularly consumed alcohol, was allowed to have alcohol stored in a safe and consumed independently, yet there was no care plan addressing his alcohol use. Staff interviews revealed that R5 consumed a significant amount of vodka daily, and although staff were aware of his alcohol consumption, no interventions were documented in his care plan. The facility's lack of a structured approach to managing R5's alcohol use highlights a significant oversight in addressing his SUD. R4, admitted with a diagnosis of alcohol use disorder, had experienced alcohol withdrawal during a prior hospitalization. Despite this, the facility did not develop a care plan to address his alcohol use. Provider notes documented R4's continued alcohol use within the facility, yet the Director of Nursing was unaware of his drinking, indicating a communication breakdown and failure to review provider notes. The facility's inaction in creating and implementing care plans for residents with SUDs demonstrates a significant deficiency in providing necessary behavioral health services.
Failure to Monitor and Manage Pressure Injuries
Penalty
Summary
The facility failed to implement appropriate interventions for a resident, R24, who was at risk for pressure injuries and had a history of such injuries. R24 was admitted with multiple diagnoses, including End Stage Renal Disease, Peripheral Vascular Disease, and a history of pressure injuries. Despite being at risk, the facility did not revise the care plan to include increased monitoring of the skin under a Controlled Ankle Movement (CAM) boot, which was applied for an ankle fracture. The boot was ordered to be worn at all times except for hygiene and icing, yet the care plan did not reflect this need for increased vigilance. R24 developed unstageable pressure injuries on the left heel and top of the foot, which were not identified in a timely manner. The facility's documentation indicated that the pressure injury was present as early as October 5, 2023, but a comprehensive assessment was not completed until October 11, 2023. The facility's wound care follow-up noted the presence of a new area on the dorsal aspect of the left foot and an unstageable pressure injury on the left heel. However, the documentation was inconsistent, as a subsequent assessment incorrectly staged the dorsal foot pressure injury. The facility's failure to revise the care plan and conduct timely assessments contributed to the development and progression of R24's pressure injuries. Despite being followed by the facility wound nurse and an Advanced Practice Nurse Practitioner, the wounds failed to heal, and further testing revealed critical lower limb ischemia. The lack of comprehensive assessment and care plan revisions for the CAM boot and pressure injury risk factors were significant deficiencies in the care provided to R24.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, R10 and R222. R10 experienced an unwitnessed fall on November 25, 2023, and the facility did not complete neurological checks as scheduled per their policy. Additionally, R10's Fall Risk Care Plan was not updated after the fall. On January 19, 2024, R10 was transferred by a CNA using a Sara Steady without the assistance of another staff member, contrary to the care plan that required two assists. This resulted in R10 falling and fracturing their left tibia, leading to hospitalization. R222 had a fall on June 6, 2024, which the facility did not thoroughly investigate. The fall occurred when R222 was found on the floor with complaints of neck and knee pain. The facility's documentation was incomplete, lacking details such as the time of the fall, the last wellness check, and the last time the resident was toileted. Staff interviews revealed inconsistencies in the account of events, and it was unclear how long R222 had been on the floor before being discovered. The facility's failure to conduct a thorough investigation and document critical information contributed to the deficiency. Both incidents highlight the facility's failure to adhere to its policies regarding fall prevention and resident supervision. The lack of proper training and adherence to care plans, as well as inadequate investigation and documentation of incidents, were significant factors leading to the deficiencies identified by the surveyors.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was prepared and served in a sanitary manner, as evidenced by improper dishwashing practices and inadequate hand hygiene by kitchen staff. The dishwashing machine was observed to not reach the required sanitizing temperature of 180 degrees Fahrenheit during the rinse cycle, with recorded temperatures ranging from 150 to 167 degrees Fahrenheit. Despite this, staff continued to use the machine to wash and sanitize dishware, potentially affecting all 76 residents in the facility. The facility's policy required dishwashing staff to monitor and record dish machine temperatures and report any issues to the food service manager, but these procedures were not effectively followed. Additionally, the facility's cook was observed handling ready-to-eat food with gloved hands after touching non-sanitized surfaces without changing gloves or washing hands. The cook was seen touching various surfaces, such as the microwave and their own nose, and then handling food items without changing gloves or washing hands. This practice was in direct violation of the facility's handwashing and glove use policies, which required staff to wash hands before donning gloves and after engaging in activities that contaminate hands. The surveyor informed the facility's management, including the Assistant Director of Nursing, Nursing Home Administrator, and Regional Consultant, about the concerns with the dishwashing machine and hand hygiene practices. However, no additional information or corrective actions were provided at the time of the survey. The facility's failure to adhere to its own policies and procedures for food safety and sanitation posed a risk to the health and safety of its residents.
Failure to Assess and Plan for Physical Restraint Use
Penalty
Summary
The facility failed to ensure that a comprehensive assessment and a plan of care were developed for the continued use of a physical restraint on a resident. The resident, who has spastic quadriplegic cerebral palsy, severe intellectual disabilities, and dysphagia, was observed with an abdominal binder in place at all times. This binder, which the resident could not easily remove, restricted the resident's freedom of movement and access to their body. The facility did not provide evidence that the abdominal binder was the least restrictive alternative, nor did they document ongoing re-evaluation of its necessity. The facility's records showed that the abdominal binder was initially ordered to prevent the resident from pulling out their g-tube during times of agitation. However, a subsequent order required the binder to be worn at all times, without a documented assessment or plan of care addressing its use. The facility's Minimum Data Set did not document the use of restraints for the resident, and the Nursing Home Administrator did not consider the binder a restraint, despite its restrictive nature. Additionally, the facility lacked a policy on restraint use, and the resident's plan of care did not adequately document the rationale, duration, or alternative interventions for the binder's use.
Failure to Complete Neurological Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neurological checks were completed following unwitnessed falls for three residents, as per the facility's policy. Resident R35, who was admitted with a primary diagnosis of alcohol dependence with alcohol-induced persisting dementia, experienced multiple falls on 9/10/2024. Despite being found with red marks on the head, neurological checks were not completed until an order was received from the nurse practitioner, several hours after the initial fall. The facility's policy required immediate and regular neurological checks following such incidents, but these were not adhered to. Resident R66 also experienced unwitnessed falls on multiple occasions, specifically on 8/5/2024, 8/17/2024, and 8/22/2024. In each instance, the scheduled neurological checks were not fully completed as required by the facility's policy. The surveyor noted discrepancies between the handwritten forms and the electronic health records, indicating that several checks were missed, which compromised the monitoring of the resident's condition post-fall. Additionally, Resident R10, who was at high risk for falls due to multiple health conditions including hemiplegia and dementia, had an unwitnessed fall on 11/25/2023. The facility's staff failed to complete the required neurological checks, missing a significant number of scheduled evaluations. This lapse in protocol was confirmed through interviews with facility staff, who acknowledged the gaps in documentation and adherence to the neurological check policy.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care consistent with professional standards of practice. The resident, who has End Stage Renal Disease and other significant health conditions, was not properly monitored for complications related to their dialysis treatment. Specifically, the facility did not implement necessary interventions to assess and document the care of the resident's arteriovenous (AV) fistula, which is crucial for ensuring adequate blood flow during dialysis. The facility's policy required coordination and communication between the skilled nursing facility staff and the dialysis center, but this was not adequately reflected in the resident's care plan or records. Interviews and record reviews revealed that the staff did not routinely assess the resident's AV fistula for pulse, bruit, and thrill, which are essential indicators of proper blood flow. The resident reported that staff rarely checked the access site, and the Assistant Director of Nursing (ADON) confirmed that there was no consistent assessment upon the resident's return from dialysis. The surveyor found no evidence of documented assessments of the AV fistula, indicating a lack of adherence to the facility's dialysis policy and procedure, which contributed to the deficiency.
Lack of Documentation for Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that the medical records of a resident contained documentation related to Pneumococcal immunizations. The resident, who was admitted to the facility, did not have any record in their electronic medical record (EMR) indicating whether they were offered, received, or declined the Pneumococcal immunization. The facility's policy on infection control and individual immunizations requires that prophylactic immunizations be offered and documented in the EMR, but this was not adhered to in the case of the resident. The Assistant Director of Nursing (ADON) acknowledged that the resident's immunization record was not addressed upon admission and was not included in the monthly immunization audit. The ADON stated that the resident was not present during the last audit and had not been offered the Pneumonia immunization. It was also noted that the facility had not yet implemented a process to address resident immunizations upon admission, although efforts were underway to improve this with the hiring of new supervisors. The deficiency was identified during a surveyor's review, and no additional information was provided to explain the lack of documentation in the resident's medical record.
Failure to Document COVID-19 Immunization Status
Penalty
Summary
The facility failed to ensure that the medical records of a resident, identified as R67, contained documentation related to COVID-19 immunizations. Upon review, it was found that R67's electronic medical record did not indicate whether the resident was offered, received, or declined the COVID-19 vaccine. The facility's policy on infection control and individual immunizations mandates that prophylactic immunizations be offered and documented in the electronic medical record. However, this was not adhered to in the case of R67, who was admitted to the facility without having their immunization status verified or documented. During an interview, the Assistant Director of Nursing (ADON) acknowledged that R67's immunization record was not included in the monthly audit of resident immunizations, which encompasses COVID-19 vaccinations. The ADON admitted that R67 was not present during the last audit and had not been offered the COVID-19 vaccine. Furthermore, the ADON revealed that the facility's process for addressing resident immunizations upon admission was still under development, with new supervisory staff being hired to assist with this process. The deficiency was only addressed after the surveyor highlighted the issue, indicating a lapse in the facility's adherence to its own immunization policy.
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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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