Meadowbrook At Black River Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Black River Falls, Wisconsin.
- Location
- 1311 Tyler St, Black River Falls, Wisconsin 54615
- CMS Provider Number
- 525488
- Inspections on file
- 32
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Meadowbrook At Black River Falls during CMS and state inspections, most recent first.
A resident with dementia and mobility limitations was left in bed for an extended period because all mechanical lift slings were being washed and unavailable. Staff confirmed the resident could not be transferred out of bed as required by their care plan, and this was communicated to the responsible party. Facility leadership acknowledged that slings should not have been washed simultaneously, resulting in the resident's ADL needs not being met.
A resident with a history of methamphetamine and alcohol use disorder did not have care plans or physician orders addressing substance use monitoring, despite facility policy. After the resident used methamphetamine during their stay, staff education lacked specific guidance on identifying or monitoring substance use, and staff interviews revealed insufficient knowledge and documentation regarding SUD assessment and monitoring.
The facility failed to administer correct anticoagulation therapy for two residents, resulting in significant medication errors. One resident did not receive the correct Warfarin dose due to a failure to verify and transcribe new physician orders, leading to an emergency department visit and additional treatment. Another resident's Warfarin orders were not properly documented or verified, indicating a systemic issue in managing anticoagulation therapy.
A resident with a history of mental health and chronic conditions self-administered medications left unattended by the DON, despite being assessed as incapable of self-administration. The facility's policy requires medications to be under direct observation or locked away, which was not followed in this instance.
A medication cart was left unlocked and unattended outside a resident's room, contrary to the facility's policy requiring all medication carts to be locked when not attended. An LPN admitted to not locking the cart, and the DON confirmed that the expectation is for all carts to be locked when unattended.
The facility did not have a qualified director of food and nutrition services, as the Dietary Manager had not started certification classes and lacked necessary qualifications. The Registered Dietician was only present one day a week, with additional support from a Certified Dietary Manager from a sister facility. This deficiency could potentially affect all 31 residents.
The facility failed to maintain a clean and sanitary environment for food preparation, affecting all 31 residents. Staff did not consistently label food items, test sanitizing solutions, or document refrigerator, freezer, and dish machine temperatures. Observations included staff touching ready-to-eat food with contaminated gloves and delivering uncovered food items to resident rooms, violating facility policies.
A facility failed to maintain proper infection control during wound care for a resident on Enhanced Barrier Precautions. An RN did not sanitize bandage scissors and a marker before and after use, and reached into their uniform pocket with contaminated gloves. The DON confirmed these actions did not follow correct procedures.
The facility did not post daily nurse staffing information at the beginning of each shift, as required by federal regulations. This issue was identified when a surveyor could not find the postings on two consecutive days. The new NHA was unaware of the posting location, and the ADON later revealed that the previous NHA had not communicated the responsibility for posting the staffing data, resulting in a lapse since October, affecting all 31 residents.
A resident with a history of elopement was admitted to a facility and managed to elope three times due to inadequate supervision. Despite being identified as an elopement risk, the facility delayed implementing interventions like a wanderguard and failed to document or increase supervision after the first two elopements. The third elopement involved the resident running through traffic and attempting to jump off a bridge, highlighting the facility's failure to provide adequate supervision and staff training.
The facility failed to adhere to professional standards for food service safety by not labeling opened milk and juice containers with use-by dates and not maintaining complete daily temperature logs for refrigerators and freezers. This deficiency had the potential to affect 31 out of 32 residents who eat orally.
A resident with a complex medical history eloped from the facility three times in one day, with the second and third incidents involving law enforcement and emergency medical intervention. Despite the seriousness of these events, the facility failed to report them to the state agency as required, and the Chief Nursing Officer and Nursing Home Administrator were unaware of the reason for the lack of reporting.
A resident with a history of heart attack, COPD, and other conditions experienced a significant decline in cognition and physical health, including hallucinations and pressure ulcers. Despite these changes, the facility did not complete a Significant Change in Status Assessment (SCSA) as required. The deficiency was identified during a surveyor's observation and interviews with staff, who confirmed the resident's refusal to reposition in bed and complete treatments.
A facility failed to follow hospital discharge orders for a resident with respiratory issues, including obstructive sleep apnea. The resident's post-discharge care instructions, which included laboratory testing and a sleep medicine evaluation, were not completed in a timely manner. Additionally, the facility did not conduct a comprehensive assessment of the resident's change in condition, which included hallucinations and physical decline.
A resident's advance directive documentation was not maintained in the facility's records. Despite being capable of understanding and communicating their wishes, the resident's CPR or DNR status was not documented in their hard charts or electronic records. Interviews with staff, including an LPN and the CNO, confirmed the absence of necessary documentation in both the electronic record and the Post Book.
A resident with Alzheimer's disease experienced a significant weight gain of 7.2% over one month, but the facility failed to notify the physician as required by their policy. Despite being aware of the weight change, the facility did not update the PCP after a five-day weight monitoring period, only doing so after a surveyor's review.
A resident with paralysis and severe cognitive impairment was found with a lap belt in their wheelchair without a physician order or documented assessment. The facility's policy on restraint management was not followed, as the restraint was used out of habit rather than medical necessity. Interviews revealed the resident could not remove the belt independently, and the ADON confirmed the lack of documentation and removed the restraint.
The facility did not provide written notices of transfer for three residents who were hospitalized. One resident was admitted to the hospital with a complicated UTI and a chronic Foley catheter, but neither they nor their representative received a notice. Medical Records C confirmed the absence of a process for issuing such notices.
The facility failed to notify two residents of its bed hold policy during hospital transfers, as required by its policy. One resident, who was his own decision maker, was hospitalized twice without receiving notification. Another resident was transferred to the hospital with a complicated UTI, and their representative was not informed of the bed hold policy. The Social Services Director could not locate the required notifications, highlighting a lapse in policy adherence.
A resident with Alzheimer's disease experienced a significant weight gain, which was not on a physician-prescribed regimen. The facility's policy requires regular weight monitoring and communication of significant changes to the attending physician. However, despite awareness of the weight changes, the Medical Doctor was not updated after a five-day monitoring period, contributing to a deficiency in maintaining the resident's nutritional status.
The facility failed to ensure proper feeding tube management for two residents, as staff used outdated auscultation methods to check tube placement, contrary to current standards. One resident with cognitive impairment and another with multiple diagnoses, including dysphagia, were affected. The facility's policy did not reflect updated practices, and staff reported a lack of training on tube feeding procedures.
Two residents requiring oxygen therapy did not receive care consistent with professional standards. One resident had outdated oxygen tubing, and another had unlabeled tubing, contrary to facility policy and physician orders. These deficiencies were confirmed by staff during a survey.
The facility failed to maintain accurate Controlled Substance Logs for four residents, with discrepancies in recorded medication quantities. An LPN could not explain the errors, and the DON acknowledged the issue, indicating plans to change the narcotic book system.
The facility failed to properly store and label medications and biologics, as expired Breeza bottles were found in stock and an opened Tuberculin Test vial lacked an opened date. An LPN and the DON acknowledged these oversights during interviews.
A long-term care facility failed to adhere to infection control protocols, as staff did not use proper PPE for residents on Enhanced Barrier Precautions (EBP). One resident receiving tube feeding was not provided care with the required gown, and another resident with a foot ulcer and on antibiotics was not placed on EBP. Staff acknowledged the oversights, and the Director of Nursing confirmed the expectations for EBP implementation.
The facility failed to prevent pressure injuries in two high-risk residents. One resident developed multiple infected pressure injuries due to a lack of routine skin assessments under a brace and ace bandage, leading to hospitalization. Another resident did not have a prescribed heel cup in place, as the care plan was not adjusted to reflect increased mobility and shoe-wearing. These deficiencies highlight a failure to adhere to pressure injury prevention protocols.
A resident experienced significant weight loss, but the facility failed to notify the physician as required by policy. Despite the resident's diagnoses of type 2 diabetes, moderate protein-calorie malnutrition, and a stage 4 pressure ulcer, there was no documentation indicating that the physician had been informed of the weight changes.
Failure to Provide Timely Transfer Due to Unavailable Lift Slings
Penalty
Summary
The facility failed to provide necessary care to ensure a resident's activities of daily living (ADLs) needs were met, specifically regarding timely transfers out of bed. According to facility policy, care should be provided in a safe, appropriate, and timely manner in accordance with the resident's care plan. The resident in question had a history of dementia, chronic pain, anemia, and mobility issues, and was dependent on staff for transfers, requiring a full body lift with two staff members. On the day of the incident, the resident was placed back in bed around 1:00 PM after their sling became soiled and was put in the wash. Staff informed the resident's responsible party that the slings were unavailable as they were being washed, and the resident remained in bed for the rest of the evening, despite requests to be transferred out of bed. Interviews with staff confirmed that the resident was not transferred out of bed due to the lack of clean slings for the mechanical lift, and this was communicated during shift changes. The Director of Nursing and the Administrator both stated that residents dependent on staff for transfers should be assisted out of bed as per their care plan and requests. The Director of Nursing also noted that all slings should not have been washed at the same time, which contributed to the unavailability of necessary equipment and the failure to meet the resident's care needs.
Failure to Assess and Monitor Resident with Substance Use Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health services for a resident with a history of substance use disorder (SUD). Despite the facility's policy requiring assessment, monitoring, and care planning for residents with SUD, the resident's care plans did not address concerns or monitoring related to substance use. The care plans focused on adjustment issues and behavior management but omitted specific interventions or monitoring for SUD, even though the resident had diagnoses including methamphetamine use disorder and alcohol use disorder in remission. Physician orders since admission also did not include any monitoring or assessment for substance use risk as outlined in facility policy. An incident occurred in which the resident was found to have used methamphetamine during their stay. Following this, staff education was provided, but it did not include guidance on assessing, monitoring, or identifying substance use. Interviews with staff revealed a lack of knowledge regarding specific signs of methamphetamine use and an absence of documentation supporting staff training on identifying, assessing, and monitoring for substance abuse in residents with a history of SUD. This demonstrates that the facility did not implement its own policy requirements for residents with SUD, resulting in a failure to ensure the resident's highest practicable mental and psychosocial well-being.
Failure to Administer Correct Anticoagulation Therapy
Penalty
Summary
The facility failed to provide appropriate anticoagulation therapy for two residents, leading to significant medication errors. For one resident, the facility did not verify and transcribe a new physician order that increased the Warfarin dose. This oversight resulted in the resident not receiving the correct Warfarin dose for several days, which led to the resident being sent to the Emergency Department. The resident required intravenous heparin and Lovenox bridging to achieve therapeutic anticoagulation levels due to the missed doses. The resident, who had a history of heart failure, a prosthetic heart valve, and other significant health conditions, was admitted to the facility with specific Warfarin dosing instructions. However, the facility failed to update the Medication Administration Record (MAR) with the new Warfarin order, resulting in missed doses over several days. The resident's condition deteriorated, leading to a transfer to a higher level of care hospital with a diagnosis of transient ischemic attack (TIA) and other complications. In another instance, the facility did not properly verify and transcribe new Warfarin orders for a second resident. The Anticoagulant Binder at the nurses' station showed incomplete documentation, with missing nurse signatures for validation of new physician orders. This lack of proper documentation and verification led to the failure to update the resident's MAR with the new Warfarin dosing schedule, indicating a systemic issue in the facility's process for managing anticoagulation therapy.
Medication Administration Lapse for Resident
Penalty
Summary
The facility failed to ensure medications were administered safely and effectively for one resident, identified as R2. During a medication pass, the Director of Nursing (DON) left R2's medications unattended on a tray table, despite a facility assessment indicating R2 was incapable of self-administering medications. R2, who has a history of paranoid schizophrenia, major depressive disorder, anxiety disorder, chronic kidney disease, and chronic respiratory failure, self-administered the medications while the DON was out of the room. Upon returning, the DON attempted to administer the medications again, only to be informed by R2 that they had already been taken. The facility's policy on self-administration of medications requires an assessment to determine a resident's capability to self-administer, and medications should not be left unattended with residents who have not passed this assessment. Despite R2's cognitive intactness as indicated by a BIMS score of 15 out of 15, the self-administration assessment showed R2 needed assistance with medication administration. The DON acknowledged that medications should not be left with residents who did not pass the self-administration assessment, indicating a lapse in following the facility's medication administration protocols.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medications were stored securely and in accordance with accepted professional practices. During an observation, a surveyor noted that one of the two medication carts was left unlocked and unattended outside a resident's room in the 300 hall. This occurred despite the facility's policy, which mandates that all drugs and biologicals be stored in locked compartments, such as medication carts, to ensure security. The incident involved a Licensed Practical Nurse (LPN) who left the medication cart unlocked while attending to a resident in their room. The LPN admitted to the surveyor that the cart is usually locked when unattended but failed to do so on this occasion. The Director of Nursing (DON) confirmed that the expectation is for all medication carts to be locked when not attended, indicating a lapse in adherence to the facility's medication storage policy.
Lack of Qualified Dietary Manager and Full-Time Dietician
Penalty
Summary
The facility failed to designate a qualified individual to serve as the director of food and nutrition services, which could potentially affect all 31 residents residing in the facility. The Dietary Manager (DM) had been in the position for approximately two weeks and had not started any classes to become a Certified Dietary Manager. During a kitchen tour, the DM admitted to not holding any certifications required for the role and was unsure if they were enrolled in a training program. The Nursing Home Administrator (NHA) believed the DM was enrolled in a Certified Dietary Manager program, but the enrollment documentation was only provided on the day of the survey. Additionally, the facility did not have a full-time Registered Dietician, as the dietician was present only one day a week and available by phone, with additional support from a Certified Dietary Manager from a sister facility one day per week.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure the preparation of food in a clean and sanitary environment, potentially affecting all 31 residents. During a kitchen tour, it was observed that staff did not consistently date or label food items when opened, as required by the facility's policy. Containers of juice and milk were found without dates, which is necessary for determining when they should be discarded. Additionally, staff did not consistently test or document the parts per million (PPM) of the quaternary sanitizing solution, with several dates missing from the test log. The facility also failed to consistently document refrigerator and freezer temperatures, which are crucial for storing potentially hazardous foods at safe temperatures. The temperature logs for December had numerous blanks, indicating non-compliance with the facility's policy. Furthermore, dish machine temperatures were not consistently recorded, with many missing entries on the temperature log, which is essential for ensuring dishes and utensils are properly sanitized. Staff were observed touching ready-to-eat food with contaminated gloves, contrary to the facility's glove usage policy. During meal service, a staff member used the same gloves to handle various surfaces and then touched food items, potentially contaminating them. Additionally, trays delivered to resident rooms contained uncovered food items, violating the facility's policy that requires food to be covered during transport through patient care and public areas.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper personal protective equipment (PPE) procedures during wound care for a resident on Enhanced Barrier Precautions (EBP). A Registered Nurse (RN) was observed providing wound care to a resident without sanitizing bandage scissors and a marking pen before and after use. The RN also reached into their uniform pocket with gloves that had been used for wound care, potentially contaminating the uniform. These actions were contrary to the Centers for Disease Control and Prevention (CDC) guidelines, which emphasize the importance of cleaning and disinfecting wound care equipment between patients to prevent cross-contamination. During the observation, the RN initially used hand sanitizer and donned a gown and gloves before entering the resident's room. However, the RN failed to sanitize the scissors after using them to cut strips of tape and again after cutting a piece of dressing for the wound. The RN also used a marker to date the dressing without sanitizing it before or after use. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the RN did not follow correct infection control procedures, acknowledging that the RN should not have reached into their uniform pocket with gloves on and should have sanitized the equipment used during wound care.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing information was posted at the beginning of each shift, as required by federal regulations. This deficiency was observed during a survey when the surveyor was unable to locate the daily nurse staffing posting on two consecutive days. On the first day, the Nursing Home Administrator (NHA), who was new to the position, was unaware of the location of the staffing postings and did not provide further information. On the second day, the Assistant Director of Nursing (ADON) revealed that the previous NHA was responsible for the postings and had not communicated this duty to anyone else upon their departure. As a result, the daily nurse staffing data had not been posted since October of that year, affecting all 31 residents in the facility.
Inadequate Supervision Leads to Multiple Elopements
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident with a known history of elopement. The resident, who had previously eloped from a hospital, was admitted to the facility under emergency protective placement. Despite being identified as an elopement risk, the resident managed to elope from the facility on three separate occasions. The first elopement occurred shortly after admission, and the resident was found outside the facility by staff. The second elopement involved the resident being missing for 2.5 hours, requiring police intervention and a K9 search to locate them. The third elopement was particularly dangerous, as the resident traveled 1.4 miles through busy traffic and attempted to jump off a bridge. The facility's policies on elopement and elopement management were not effectively implemented. The resident's elopement risk was not adequately addressed in their care plan, and the interventions, such as the placement of a wanderguard, were delayed. The facility also failed to document the first and second elopements in the resident's medical record and did not increase supervision or implement additional interventions after these incidents. The staff on duty during these events were not adequately trained or prepared to handle the situation, as evidenced by the agency nurse's lack of knowledge in operating the facility's alarm system. The facility's inaction and lack of proper supervision created a situation of immediate jeopardy, as the resident's safety was compromised multiple times. The facility did not have sufficient staff to provide the necessary supervision, and the interventions that were in place, such as 15-minute checks, proved ineffective. The facility's failure to act promptly and appropriately in response to the resident's elopement risk led to repeated incidents that endangered the resident's well-being.
Removal Plan
- All staff education included supervision when a resident displays exit seeking behavior.
- Resident assisted to a common area.
- Resident engaged in activities of interest.
- Resident provided psychosocial support.
- Resident family contacted and included if able.
- Increased visits from facility managers.
- Staff coordination on who will be providing the increased supervision and for how long and when to provide relief.
- If resident behaviors continue, increased 1:1 support may be needed per staff discussion which includes DON/NHA/designee.
- Wanderguard does not replace supervision. Staff should be proactive and increase supervision as needed when resident displays exit seeking behavior.
- Staff should contact DON/NHA/designee for additional support and guidance.
- All elopement risk assessments were updated.
- All elopement residents' care plans were updated.
Deficiency in Food Handling and Temperature Logging
Penalty
Summary
The facility failed to ensure the safety of food handling in accordance with professional standards for food service safety. During an inspection, it was observed that milk and juice containers in the walk-in cooler were opened but not labeled with an opened date or use-by date. This oversight was contrary to the facility's policy, which requires all refrigerated and prepared food to be covered, labeled, and dated with a use-by date that is a maximum of seven days from the date of preparation. The Dietary Manager confirmed that the expectation was for opened milk and juice to be labeled with a use-by date using stickers provided by the facility. Additionally, the facility did not maintain complete daily temperature logs for refrigerators and freezers, as required by their policy. The surveyor noted missing entries for freezer temperatures on specific dates, which could potentially lead to foodborne illness. The Dietary Manager acknowledged that the expectation was for temperatures to be recorded twice daily, which was not being adhered to. This deficiency had the potential to affect 31 out of 32 residents who consume food orally.
Failure to Report Resident Elopements and Misconduct
Penalty
Summary
The facility failed to report an incident of potential misconduct involving a resident's elopements to the state agency immediately upon learning of the incident and did not submit the required 5-day investigation report. The deficiency involved a resident who was admitted to the facility under emergency protective placement with a history of encephalopathy, amnesia, disorientation, and other medical conditions. The resident eloped from the facility three times on the same day, with the second and third elopements involving law enforcement and emergency medical intervention. During the first elopement, the resident exited through an employee door, triggering an alarm, and was redirected back into the facility by a CNA. Shortly after, the resident eloped again through an emergency door and was found by law enforcement two blocks away. The third elopement involved the resident attempting to jump off a bridge, requiring intervention by staff and a civilian. Despite these serious incidents, the facility did not report them to the Department of Quality Assurance (DQA) as required, and the Chief Nursing Officer and Nursing Home Administrator were unaware of the reason for the lack of reporting.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a significant change in physical condition and cognition. The resident, who had a history of heart attack, COPD, type 2 diabetes mellitus, obesity, and chronic kidney disease, was initially assessed with intact cognition and required substantial assistance with daily activities. However, the resident began experiencing hallucinations, was hospitalized for respiratory failure, and upon readmission, continued to exhibit delusions and a decline in cognitive and physical condition. Despite these changes, the facility did not complete a SCSA as required by their policy. The resident's condition continued to deteriorate, with progress notes indicating increased carbon dioxide levels, hallucinations, and the development of pressure ulcers. The facility's staff, including the Nursing Home Administrator, acknowledged that the resident met the criteria for a SCSA, but it had not been completed timely. The facility was in the process of obtaining physician signatures to determine the resident's capacity to make healthcare decisions and had scheduled a psychiatric evaluation. The deficiency was identified during a surveyor's observation and interviews with facility staff, who confirmed the resident's refusal to reposition in bed and complete prescribed treatments.
Failure to Follow Hospital Discharge Orders and Assess Change in Condition
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who had a history of respiratory issues including obstructive sleep apnea and chronic obstructive pulmonary disease, was discharged from the hospital with specific instructions for follow-up care. These instructions included laboratory testing five days post-discharge and a sleep medicine evaluation due to the resident's refusal to use a CPAP device. However, the facility did not adhere to these discharge orders, as the laboratory tests were conducted 22 days after discharge, and the sleep study was scheduled much later. Additionally, the resident experienced a change in condition, including hallucinations and physical decline, which the facility did not comprehensively assess. Despite the resident's intact cognition as indicated by a BIMS score of 15/15, the facility failed to address the resident's ongoing issues promptly. The lack of timely follow-up on the hospital's discharge instructions and the inadequate assessment of the resident's change in condition contributed to the deficiency identified by the surveyors.
Failure to Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to formulate and maintain an advance directive for Resident 236, who was admitted to the facility and was capable of understanding and communicating their wishes. During a survey, it was found that there were no orders for a Cardiopulmonary Resuscitation (CPR) or Do-Not-Resuscitate (DNR) status in the resident's hard charts or electronic records. The surveyor could not locate any provider orders related to advanced directives for this resident. Interviews with facility staff, including a Licensed Practical Nurse (LPN), Medical Records (MR) personnel, and the Chief Nursing Officer (CNO), revealed that the expected documentation for advanced directives was missing. The LPN indicated that such information should be available in the electronic record and the Post Book organized by room location. However, neither the hard charts nor the books at the nurses' station contained the necessary documentation. The CNO confirmed that they also could not find the required documentation, which should have included doctor orders, face sheet documentation, and a Physician Orders for Scope of Treatment (POST) sheet.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to consult with a physician regarding a significant weight gain experienced by a resident, identified as R26. The facility's policy mandates physician notification for significant weight changes, defined as a gain or loss of 5% or more in the past 30 days. R26, who has Alzheimer's disease, hypertension, and chronic pain, showed a weight increase from 178 pounds to 191.4 pounds between August 2, 2024, and September 4, 2024, representing a 7.2% gain in one month. Despite this, there was no documentation indicating that the primary care provider (PCP) was informed of this significant change. The facility was aware of the weight changes, as the information was recorded in their system. However, the Assistant Director of Nursing (ADON) confirmed that the PCP was not updated about the weight gain after a five-day period of daily weight monitoring, which was ordered due to discrepancies in recorded weights. The failure to notify the PCP occurred despite the facility's policy and the physician's order for weekly weight checks. The PCP was eventually informed on October 7, 2024, but this was after the surveyor's review and interview with the ADON.
Failure to Justify and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints that were not required to treat medical symptoms. The resident, who had a history of paralysis and severe cognitive impairment following a stroke, was observed with a lap belt in his wheelchair. There was no physician order, medical symptom justification, or assessment documented for the use of this restraint. The resident's care plan did not include the use of a restraint, and the facility's policy on restraint management was not followed. Interviews with the resident's family member and facility staff revealed that the lap belt was used out of habit, as it came with the wheelchair, and not due to a medical necessity. The resident was unable to remove the lap belt independently, indicating it functioned as a restraint. The facility's Assistant Director of Nursing confirmed the lack of documentation supporting the restraint's use and subsequently removed it, acknowledging that the resident did not require it.
Failure to Provide Written Notices of Transfer for Hospitalized Residents
Penalty
Summary
The facility failed to provide timely written notices of transfer to three residents who were hospitalized, as required by regulations. Resident 11 and Resident 28 were both hospitalized on separate occasions but did not receive written notices of their transfers. Similarly, Resident 20 experienced a change in condition and was transferred to the emergency room, later being admitted to the hospital with a complicated urinary tract infection and a chronic indwelling Foley catheter. Despite this, no written notice of transfer was provided to Resident 20 or their representative. During an interview, Medical Records C confirmed that the facility lacked a process for issuing written notices of transfer when residents are hospitalized.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that two residents, identified as R28 and R20, received written notification of the facility's bed hold policy when they were transferred to the hospital. According to the facility's policy, when a resident is transferred to a hospital or requests a therapeutic leave, the center is required to provide written notice to the resident or their representative regarding the bed hold rights and policy. This policy states that a resident's bed will be held automatically for 15 days at 100% of the current daily rate unless otherwise notified. However, during the survey, it was found that R28, who was his own decision maker, was hospitalized twice, and there was no evidence that he was notified of the bed hold policy during these hospitalizations. Similarly, R20 experienced a change in condition and was transferred to the emergency room, later being admitted to the hospital with a complicated urinary tract infection. The surveyor reviewed R20's records and found no evidence that R20's representative was notified of the bed hold policy at the time of hospitalization. The Social Services Director was interviewed and reported being unable to locate the bed hold notifications for the hospitalizations of both R28 and R20, indicating a lapse in the facility's adherence to its own policy.
Failure to Monitor and Communicate Significant Weight Gain
Penalty
Summary
The facility failed to ensure acceptable parameters of nutritional status for a resident, identified as R26, who experienced a significant weight gain. The facility's policy on weight management requires regular monitoring of residents' nutritional status, including obtaining routine weights. However, R26, who has Alzheimer's disease, hypertension, and chronic pain, experienced a weight gain of 7.2% in one month, which was not on a physician-prescribed weight gain regimen. The facility's records showed that R26's weight increased from 178.6 lbs to 191.4 lbs over a period, indicating a significant change that should have been addressed according to the facility's guidelines. Despite the facility's awareness of the weight changes through their computer system, the Medical Doctor was not updated regarding the weight gain after a five-day period of daily weight monitoring. The facility's policy requires that significant weight changes be communicated to the attending physician and documented in the resident's progress notes. However, this communication did not occur, as confirmed by the Assistant Director of Nursing during an interview. This lack of communication and failure to follow the facility's weight management policy contributed to the deficiency in maintaining the resident's nutritional status.
Deficiency in Feeding Tube Management and Staff Training
Penalty
Summary
The facility failed to ensure that residents with feeding tubes received appropriate treatment and services to prevent complications and restore oral eating skills. Specifically, the facility did not adhere to current standards for checking feeding tube placement for two residents. The facility's policy, dated April 2024, required licensed nurses to verify tube placement before feedings and medication administration. However, the policy did not reflect updated standards, as it still endorsed the auscultation method, which is no longer recommended. Resident R24, who had multiple diagnoses including cognitive impairment, was observed having their feeding tube placement checked using the auscultation method by a registered nurse, contrary to current best practices. The Director of Nursing was unaware of the recent policy change, indicating a lack of communication and training regarding updated procedures. Similarly, Resident R13, with diagnoses including moderate protein-calorie malnutrition and dysphagia, also had their feeding tube placement checked using the auscultation method by an LPN. The LPN did not check for residual fluid or assess for gastric discomfort before administering medications, which is a deviation from proper protocol. The LPN reported not receiving any training on tube feeding from the facility since starting their position, highlighting a gap in staff education and training. These deficiencies indicate a systemic issue in the facility's adherence to updated standards and staff training regarding feeding tube management.
Failure to Adhere to Oxygen Tubing Change Protocols
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents requiring oxygen therapy. Resident 11, who has a history of chronic obstructive pulmonary disease (COPD) and other respiratory conditions, was observed with oxygen tubing dated several months prior, despite physician orders to change the tubing weekly. The facility's policy also mandates weekly changes, yet the treatment administration record falsely indicated compliance with this requirement. This discrepancy was confirmed by a Licensed Practical Nurse (LPN) who acknowledged the outdated tubing and proceeded to change it immediately. Similarly, Resident 29 was found using unlabeled oxygen tubing, contrary to the facility's expectations for labeling during each change. The Assistant Director of Nursing (ADON) was in the process of replacing the tubing when questioned by the surveyor, admitting the oversight. These observations highlight a failure in adhering to prescribed respiratory care protocols, as evidenced by the outdated and unlabeled oxygen tubing for both residents.
Inaccurate Controlled Substance Logs in LTC Facility
Penalty
Summary
The facility failed to maintain an accurate and reliable system for accounting the receipt, usage, disposition, and reconciliation of controlled medications for four residents. The Controlled Substance Logs were found to be inaccurate, with discrepancies in the recorded quantities of medications before and after administration. For instance, the logs showed incorrect remaining quantities after doses were administered to residents, indicating a lack of precise record-keeping. The facility's policy on Controlled Substance Management, which aims to prevent loss, diversion, or accidental exposure, was not effectively implemented, as evidenced by the inaccuracies in the logs. During interviews, a Licensed Practical Nurse (LPN) was unable to explain the discrepancies or identify the initials responsible for the errors. The Director of Nursing (DON) acknowledged the inaccuracies and expressed an intention to change the current system of narcotic books. The deficiencies were identified through a combination of interviews and record reviews, highlighting a systemic issue in the facility's management of controlled substances.
Deficiency in Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored and labeled according to currently accepted professional principles. During an inspection, it was observed that expired medications and biologics were not removed from the stock supply in the medication storage room. Specifically, two bottles of Breeza, a beverage used for neutral abdominal imaging, were found with expiration dates of 9/22, indicating they were expired and still present in the general stock. Additionally, an opened multidose vial of Tuberculin Test, Tubersol Injection, was found without an opened date written on it, contrary to the facility's guidelines which require such vials to be dated when opened and discarded after 30 days. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed the oversight. The LPN acknowledged that the expired Breeza bottles were "really old" and should have been discarded, and subsequently removed them from the shelf. The LPN also admitted that the Tuberculin Test vial should have been marked with the date it was opened. The DON agreed with these assessments, acknowledging that the expired biologics should have been discarded and the opened vial should have been properly dated.
Inadequate Infection Control Practices in LTC Facility
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) when providing care to residents. In the first instance, a Registered Nurse (RN) did not wear a gown while performing a tube feeding for a resident on EBP, despite the presence of signage indicating the requirement for gown and gloves. The RN acknowledged the oversight during an interview, admitting that they were aware of the protocol but failed to follow it at that time. The Chief Nursing Officer and Director of Nursing confirmed that the expectation was for staff to wear both gown and gloves during such procedures. In another instance, a resident with a foot ulcer and on antibiotics for osteomyelitis was not placed on EBP, despite having open wounds and being on antibiotic treatment. A Licensed Practical Nurse (LPN) acknowledged that the resident should have been on EBP and planned to implement it after the surveyor's inquiry. The Director of Nursing confirmed that it was the nurses' responsibility to place residents on EBP when necessary, and that the resident's condition warranted such precautions.
Failure to Prevent Pressure Injuries in High-Risk Residents
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for two residents at high risk. One resident was admitted with a brace and ace bandage on her leg and was identified as being at risk for pressure injuries. However, the facility did not develop a care plan or routinely assess the skin under the brace and ace bandage, leading to multiple pressure injuries. These injuries became infected, requiring hospitalization and surgical intervention. The facility's policy on pressure injury prevention was not followed, as the skin under medical devices was not inspected as required. The resident's care plan did not include interventions for skin care or pressure injury prevention, and there was a lack of documentation regarding skin assessments. Despite having a high Braden score indicating risk, no pressure-reducing devices or nutritional interventions were utilized. The facility also failed to clarify discharge instructions regarding the removal of the leg brace, contributing to the development of pressure injuries. Another resident, who was at risk for pressure injuries due to decreased mobility and muscle weakness, did not have the prescribed heel cup in place as required. The facility did not adjust the care plan to reflect the resident's increased mobility and shoe-wearing, leading to a failure in following the plan of care. This oversight was discovered during a surveyor's review, indicating a lack of adherence to the prescribed interventions for pressure injury prevention.
Removal Plan
- Provide education to all nursing staff on skin policies and procedures, including admission assessments, and implementing orders to check skin under medical devices daily for signs of pressure related injuries, and timely updates with new skin issues/breakdown with orders obtained and care plans updated.
- Provide education to the Interdisciplinary Team (IDT) on new admission review to ensure skin assessments are completed and schedule is in place in the treatment administration record (TAR) to check under any medical device daily for signs of pressure related injuries.
- Provide education to all nursing staff, minimum data set (MDS) coordinator, and IDT on ensuring care plans with specific interventions are implemented for all residents at risk of developing pressure injuries. Education including review of care plans, evaluations of effectiveness of interventions, and addition of new interventions if needed.
- Perform a facility-wide skin sweep to ensure all residents at risk for pressure injuries have care planned interventions, all current skin conditions are documented and on the weekly wound tracking document, and any new skin concerns are identified, and the physician and resident's power of attorney (POA) if applicable are updated with orders obtained and care plan updates are made.
- Director of Nursing (DON)/designee will conduct new admission audits daily to ensure orders are in place to check under medical devices for those utilizing.
- DON designee will conduct weekly audits of resident care plans to ensure interventions are in place and effective for those at risk for pressure injuries.
- Medical devices added to IDT daily clinical board to ensure orders in place for skin monitoring.
- The results of all audits will be brought to monthly quality assurance performance improvement (QAPI) meeting to determine effectiveness and if additional audits or education are needed.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician about significant weight loss, which is a violation of their policy. The policy requires the director of nursing or designee to notify the attending physician of significant weight changes and document it in the resident's progress notes. The resident in question, who has diagnoses including type 2 diabetes, moderate protein-calorie malnutrition, and a stage 4 pressure ulcer, experienced a significant weight loss from 258.2 pounds on admission to 171 pounds over several months. Despite this, there was no documentation indicating that the physician had been notified of the weight loss. The surveyor reviewed the resident's medical chart and found no notifications made to the resident's physician regarding the significant weight variance. When the surveyor requested any medical doctor notifications from the Nursing Home Administrator, the Corporate Registered Nurse confirmed that there was no indication that the physician had been notified about the weight loss. This oversight had the potential to affect the resident's health and well-being, as timely medical intervention was not sought for the significant weight loss.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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