Meadowbrook At Chetek
Inspection history, citations, penalties and survey trends for this long-term care facility in Chetek, Wisconsin.
- Location
- 725 Knapp St, Chetek, Wisconsin 54728
- CMS Provider Number
- 525672
- Inspections on file
- 21
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Meadowbrook At Chetek during CMS and state inspections, most recent first.
The facility failed to prevent multiple significant medication errors when staff did not consistently verify medications against orders, left a med cart unattended, and did not remove discontinued drugs from circulation. A resident with orthostatic hypotension was given another resident’s Oxycontin ER and Amlodipine and required Narcan and hospitalization. Another resident with rib fractures received a discontinued opioid instead of the current pain medication. A hospice resident prescribed Lorazepam oral concentrate was repeatedly given tablet form and later received a dose after the drug was discontinued. Additional errors included a wrong Tacrolimus dose due to transcription error, a resident receiving another resident’s Atorvastatin, and a resident ingesting another resident’s gabapentin, clonidine, and Vitamin D after bedside medication cups were mixed up for two residents with the same initials.
A resident with orthostatic hypotension and a neurocognitive disorder received another resident’s medications, including Oxycontin ER and Amlodipine, from a licensed nurse, leading to administration of Narcan and hospital evaluation where the resident was found markedly orthostatic and required IV fluids and transfer to another hospital. Despite the facility’s abuse prevention policy defining possible neglect as failure to provide necessary goods or services to avoid harm, the DON reported that the incident was not reported to the state agency and the required 5-day investigation was not submitted on time, citing that it was the nurse’s first medication error and that there were no noted signs or symptom effects.
The facility failed to thoroughly investigate and promptly correct an initial opioid medication error, allowing additional serious medication errors to occur. A resident with rib fractures received a discontinued opioid that had not been removed from circulation. Subsequently, another cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER and Amlodipine, and required Narcan, ED care, and hospital transfer. A cognitively intact hospice resident with COPD, chronic pancreatitis, and anxiety, ordered Lorazepam oral concentrate, instead received the wrong dosage form (tablet) on multiple occasions and later received the medication again after it had been discontinued, as it was not removed from circulation. These errors occurred despite existing policy requiring verification of medication labels against orders and after management became aware of the first error but before all licensed nurses were educated.
Two residents were affected when the facility failed to follow its own policy for controlled substance destruction and discontinuation. For one resident, a discontinued Pregabalin (Lyrica) 50 mg order was not destroyed promptly and was documented as destroyed by only one nurse instead of two licensed staff. For another resident, Lorazepam ordered as an oral concentrate for terminal anxiety was logged as 0.5 mg tablets, and the controlled substance log showed doses being administered after the medication had been discontinued. The DON and ADON acknowledged awareness of these medication errors, while an RN described a destruction process involving a drug buster and two nurse signatures that was not followed in these instances.
Two residents did not receive medications in accordance with physician orders and labeling requirements. One hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder was ordered Lorazepam oral concentrate for terminal anxiety but was repeatedly given tablet doses instead, and the drug continued to be administered after it was discontinued. In a separate case, an RN was found using an unlabeled morphine oral solution bottle marked only with a handwritten number, later identified as belonging to a resident, and confirmed that this medication had been administered multiple times without proper labeling or resident identification.
The facility did not accurately report direct care staffing data to CMS via the PBJ system, resulting in underreported weekend staffing levels. Although management and HR staff stated that weekend staffing was consistent with weekdays, a review revealed that hours worked by staff who left employment before data was pulled were omitted from PBJ submissions. This led to the facility being flagged for low weekend staffing, potentially affecting all residents.
A resident with upper limb monoplegia and COPD, requiring assistance with mobility, was found unable to reach their call light, which was wrapped around a bedside rail. The resident reported that staff frequently left the call light out of reach after transfers, despite care plan instructions and facility policy requiring accessibility to minimize fall risk. The DON confirmed staff were aware of the resident's limitations and the need for the call light to be within reach.
A resident with multiple medical conditions and existing pressure injuries did not receive wound care as ordered by the physician. During observed care, an RN failed to perform hand hygiene, did not follow the prescribed wound care steps, and omitted the application of required treatments, resulting in a deficiency in both infection control and adherence to professional standards.
Two residents were not adequately protected from accident hazards: one with severe cognitive impairment and high fall risk was left unsupervised in the bathroom, resulting in a fall, while another resident who vapes was not properly assessed or care planned for independent smoking, despite facility policy requiring such evaluation.
A resident requiring dialysis did not receive consistent pre- and post-dialysis assessments as required by facility policy and the care plan. Staff failed to document vital signs, weight, or inspection of the dialysis access site before or after dialysis treatments, and the DON confirmed that there was no established process for these assessments. The resident reported that vital signs were only sometimes checked after dialysis, and records showed only weekly documentation unrelated to dialysis sessions.
Staff failed to follow infection control protocols, including proper hand hygiene during wound and personal care, use of PPE for a resident with open wounds, and correct handling of a urinary catheter bag, which was repeatedly observed on the floor. These lapses involved multiple residents with complex medical needs and were not in accordance with facility policies.
The facility failed to follow its food storage and labeling policies, leading to multiple unlabeled and potentially expired food items in the walk-in refrigerator and resident kitchenette. The Dietary Manager and staff admitted to not labeling items with open dates, and expired items were found. The Nursing Home Administrator was unaware of any foodborne illnesses but acknowledged the deficiency after being informed by the Dietary Manager.
A facility failed to return a deceased resident's trust funds to the POA or family within 30 days, as required by policy. The resident's account showed a positive balance, but no conveyance was documented. A family member reported the facility refused to refund the balance, citing an outstanding debt. The NHA was unsure about the balance, and the Accounts Receivable Specialist claimed all accounts are usually settled within 30 days, highlighting a lapse in policy adherence.
Two residents experienced falls that were not immediately reported to the physician, violating the facility's policy. One resident with Alzheimer's disease fell and was not reported until a day later, while another resident with dementia had two unwitnessed falls, with no documentation of physician notification. The DON was unaware of the incidents until observing injuries.
Two residents in an LTC facility did not receive proper assessments following falls, as required by the facility's fall management policy. One resident, with severe cognitive impairment, was not thoroughly assessed after a fall, and the incident was not reported to hospice or family until the next day. Another resident, with dementia, experienced falls without documented assessments, and the DON was unaware of the incidents until observing facial bruising. These deficiencies highlight a failure in maintaining residents' well-being and communication protocols.
The facility failed to implement new fall interventions for three residents at risk for falls. One resident fell and had a planned intervention not added to their care plan. Another resident experienced two falls with no new interventions implemented. A third resident's care plan was not updated after a fall. The DON acknowledged the oversight.
The facility failed to ensure proper hand hygiene and use of hair nets in food service. A CNA entered the kitchen without a hair net, and a Dietary Cook handled food without changing gloves or using hand hygiene after touching unclean items. The Dietary Manager confirmed these practices were against facility policy.
A facility failed to follow physician orders to schedule a follow-up oncology appointment for a resident with a potentially metastatic lesion. The admission checklist process was not effectively executed, and the necessary information was not communicated to the Social Services Assistant responsible for scheduling. Staff interviews revealed confusion and a lack of timely action, resulting in the resident not receiving the required follow-up care.
The facility failed to evaluate hazards related to the use of an oscillating percussion vest for a resident with quadriplegia and high aspiration risk. The resident was observed alone during vest treatments, and staff did not consistently follow physician orders for post-treatment checks. The care plan lacked details on supervision during vest use, and no assessment was conducted to ensure the resident's safety while unsupervised.
A resident with epilepsy, cerebral palsy, and functional intestinal disorder received medication via G-tube without proper verification of tube placement. The LPN used an outdated method of injecting air and listening for noise, which is no longer the standard of practice. The facility's policy still included this outdated practice, leading to the deficiency.
The facility failed to maintain an effective infection prevention and control program. Staff did not perform proper hand hygiene during medication administration for a resident with severe cognitive impairment, and droplet precautions were removed prematurely for a COVID-19 positive resident due to a miscalculation of isolation days.
Multiple Significant Medication Errors and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, despite a policy requiring accurate, safe, and timely medication administration. The policy directs staff to verify medication labels against the medication sheet for accuracy of drug, frequency, duration, strength, and route, and to check physician orders if there is any discrepancy. In multiple instances, staff did not follow these procedures, resulting in residents receiving wrong medications, wrong doses, wrong dosage forms, and discontinued medications that had not been removed from circulation. One cognitively intact resident with orthostatic hypotension and neurocognitive disorder with Lewy bodies was given another resident’s medications after an RN left a medication cart unattended between two rooms and then returned and handed the wrong medications to the resident. The medications included Oxycontin ER 20 mg and Amlodipine 5 mg, and the resident subsequently required Narcan and hospitalization, with hospital records later documenting marked orthostatic blood pressure changes requiring IV electrolytes and hydration. Another resident admitted with multiple rib fractures had an order for Oxycodone 5 mg every 6 hours for pain that was discontinued and changed to Hydrocodone 5-325 mg; however, the discontinued Oxycodone was not removed from circulation, and the resident received the wrong opioid medication on a later date. A resident on hospice care with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of liquid on multiple dates. The Lorazepam was later discontinued but not removed from circulation, resulting in an additional dose being administered after discontinuation. Pharmacy review identified that another resident’s Tacrolimus dose was incorrectly transcribed in the medical record as 5 mg, two tablets twice daily instead of the ordered 0.5 mg, two tablets twice daily, and the resident received the wrong dose at morning administration. In separate incidents, one resident received another resident’s 40 mg Atorvastatin tablet, and another resident took another resident’s medications (gabapentin, clonidine, and Vitamin D) after medication cups were set at the bedside for two residents with the same initials, and one resident ingested the medications without checking the cup.
Failure to Timely Report Medication Error and Potential Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely report an incident of potential neglect to the state survey agency after a resident received the wrong medications, required Narcan, and was hospitalized. The facility’s abuse prevention policy defines possible neglect as the failure to provide goods or services necessary to avoid physical harm, pain, mental anguish, or emotional distress, or that could reasonably be expected to cause pain, injury, or death. The resident involved was admitted with orthostatic hypotension and a neurocognitive disorder with Lewy bodies, and had a BIMS score of 14/15, indicating intact cognition, with an activated power of attorney for health care. On the date of the incident, a licensed nurse administered medications intended for another resident, including Oxycontin ER 20 mg and Amlodipine 5 mg, to this resident. The physician was contacted immediately, Narcan was ordered and administered, and the resident was sent to the emergency department for observation of the medication error. In the hospital, the resident was found to be markedly orthostatic and received IV electrolytes and hydration, and was later transferred to another hospital when blood pressure began trending low, before eventually returning to the facility. During an interview with the surveyor, the DON stated the incident was not reported to the state agency because it was the nurse’s first medication error and there were no noted signs or symptom effects of receiving the wrong medication, and acknowledged that the 5-day investigation was not submitted within the required 5 days.
Failure to Investigate and Correct Medication Errors Leading to Multiple Significant Drug Administration Mistakes
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough and timely investigation and to implement corrective actions after an initial significant medication error, which allowed additional serious errors to occur. Facility policy on Medication Administration, revised 12/2025, requires accurate, safe, and timely administration of medications and verification of the medication label against the medication sheet, with physician orders checked if there is any discrepancy. Despite this, one resident admitted with multiple rib fractures was initially prescribed Oxycodone 5 mg every 6 hours for pain, which was discontinued and changed to Hydrocodone 5-325 mg every 6 hours on 06/26/25. On 07/02/25, this resident was administered the previously discontinued Oxycodone, which had not been removed from circulation. Following that event, the facility did not ensure that all licensed nurses were educated on medication administration requirements before their next shifts, and two further significant medication errors occurred. One cognitively intact resident with orthostatic hypotension and Lewy body neurocognitive disorder was given another resident’s medications, including Oxycontin ER 20 mg and Amlodipine 5 mg, and required Narcan and transfer to the ED, where the resident was found to be markedly orthostatic and required IV electrolytes and hydration before transfer to another hospital when blood pressure trended low. Another cognitively intact hospice resident with COPD, chronic pancreatitis, and generalized anxiety disorder had been prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, which was discontinued on 06/19/25 but not removed from circulation. The controlled substance log showed that this resident repeatedly received the wrong dosage form (tablet instead of liquid) on multiple dates and again received the wrong form and a discontinued medication on 07/06/25. These events occurred while nurse management were aware of the initial error but had not yet ensured all licensed staff were educated prior to subsequent shifts.
Failure to Properly Destroy and Discontinue Controlled Substances
Penalty
Summary
The facility failed to ensure proper destruction and disposition of controlled substances for two residents, contrary to its policy requiring unused, contaminated, or expired prescription drugs to be disposed of in accordance with state laws and with a witness to the destruction. For one resident, documentation showed an order for Pregabalin (Lyrica) 50 mg capsules twice daily that was later discontinued and changed to Pregabalin (Lyrica) 75 mg twice daily. The narcotic sheet for the 50 mg dose had an "X" across the sheet with a notation "Destroyed RN" and only one nurse’s signature. During interview, the DON stated that controlled substances should be discarded right away once it is known the resident will not be using them or when the provider discontinues the order, and acknowledged that the 50 mg Pregabalin should have been destroyed immediately and with two licensed staff, but was not. For another resident, Lorazepam oral concentrate 0.25 ml every four hours as needed for terminal anxiety was prescribed, but the facility’s controlled substance log initiated for this resident was labeled for Lorazepam 0.5 mg tablets. The log showed documentation that the resident continued to receive Lorazepam after the medication had been discontinued. In interviews, the DON and ADON acknowledged awareness of medication errors related to this situation. A registered nurse described the usual process for controlled substance destruction as using a drug buster in the medication storage room with two nurses signing off and verifying destruction, which contrasted with the documented practice in these cases.
Improper Labeling and Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure medications were properly labeled, stored, and administered according to physician orders and facility policy for two residents. One resident with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was admitted on 03/21/25 and placed on hospice care on 06/02/25. On that date, the resident was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of the ordered liquid concentrate. The controlled substance log initiated on 06/02/25 was labeled for Lorazepam 0.5 mg tablets, and documentation showed the resident received the wrong dosage form on multiple dates (06/04/25, 06/05/25, 06/06/25, 06/09/25, and 06/10/25). Additionally, the Lorazepam was discontinued on 06/19/25 but was not removed from circulation, and the resident received an additional dose without a physician’s order on 07/06/25. In a separate incident, a surveyor observed an RN at the medication cart and asked about narcotic administration. The RN presented the narcotic box, where the surveyor observed a morphine bottle with no label identifying the resident, the correct dose, or other required information, only a handwritten “#36” in permanent marker. When questioned, the RN had to search through narcotic records to determine that the bottle belonged to another resident and confirmed that the morphine oral concentration bottle was not properly labeled with the resident’s name, date of birth, pharmacy dispense date, or other identifying information. The RN acknowledged that this morphine had been administered 13 times without proper labeling and stated they had not realized the resident’s name was missing from the bottle. The DON later stated that liquid medications, especially morphine, were expected to be correctly labeled and that unlabeled morphine should not be administered.
Inaccurate PBJ Staffing Data Submission Resulting in Underreported Weekend Staffing
Penalty
Summary
The facility failed to ensure accurate reporting of direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system. Despite facility staff, including the DON and HR, stating that weekend staffing levels were consistent with weekday staffing and that call-ins did not differ between weekends and weekdays, the PBJ data submitted for multiple fiscal quarters indicated excessively low weekend staffing. Upon review, it was discovered that the process used by Corporate HR to pull and enter staffing data into the PBJ system was flawed. Specifically, if a staff member left employment before the data was pulled, their name and corresponding hours worked were deleted from the report, resulting in underreporting of actual hours worked. This underreporting led to inaccurate PBJ submissions, which triggered the facility to be flagged for low weekend staffing. The deficiency was identified through interviews with facility leadership and review of submitted PBJ data, schedules, and staff postings, which confirmed that multiple staff hours worked on weekends were not reported. This issue had the potential to affect all 71 residents residing in the facility, as the reported staffing levels did not accurately reflect the care provided.
Failure to Ensure Call Light Accessibility for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when a resident with monoplegia of the upper limb and COPD was not provided reasonable accommodation for their needs, specifically regarding access to their call light. The resident's care plan required that the call light be kept within reach due to their risk for falls and limited mobility. However, during an observation, the resident was found sitting in a wheelchair with the call light wrapped around the far-left bedside rail, out of reach. The resident was heard yelling for help and reported that staff often forgot to place the call light within reach after transfers from bed to wheelchair. The resident's most recent assessment indicated intact cognition and a need for partial to moderate assistance with mobility. The facility's fall management policy required adequate supervision and assistive devices to minimize fall risk. Despite this, staff failed to ensure the call light was accessible, as confirmed by both the resident and the DON, who acknowledged staff awareness of the resident's limitations and the importance of call light accessibility.
Failure to Follow Wound Care Orders and Infection Control During Pressure Injury Treatment
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, end stage renal disease, diabetes mellitus type 2, peripheral vascular disease, and chronic venous insufficiency, was admitted to the facility with several pressure injuries (PIs) and diabetic foot ulcers. The resident was dependent on staff for most activities of daily living and was identified as being at risk for pressure injuries. Physician orders specified a detailed wound care regimen, including cleansing, application of skin prep, Santyl ointment, calcium alginate, and zinc oxide to specific areas, to be performed daily and as needed. During a surveyor's observation, a registered nurse failed to follow proper infection control protocols and did not adhere to the physician's wound care orders. The nurse entered the resident's room without performing hand hygiene, donned gloves, and proceeded with wound care without changing gloves or sanitizing hands between steps. The nurse also omitted key steps in the wound care process, such as applying skin prep and Santyl ointment before the calcium alginate, as ordered. These actions were confirmed by the Assistant Director of Nursing, who acknowledged that hand hygiene and adherence to wound care orders were not followed during the observed care.
Failure to Prevent Accidents and Inadequate Supervision for Residents at Risk
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident with a history of cerebral infarction, severe cognitive deficit, generalized weakness, and osteoporosis was assessed as high risk for falls and required dependent assistance with toileting. Despite care plan interventions specifying that staff should remain with the resident while in the bathroom, the resident was left unsupervised for approximately 20 minutes, resulting in an unwitnessed fall. The resident was not observed to use the call light, and staff did not return to check on the resident during this period, contrary to the care plan and facility expectations. Another resident, who is cognitively intact but dependent on staff for toileting hygiene, lower body dressing, and transfers, was not properly assessed for independent vaping or smoking. Although the facility's policy requires an evaluation for all residents who use tobacco products or e-cigarettes, the resident was listed as able to smoke independently without a completed assessment or a care plan addressing vaping or smoking. The resident reported being able to go outside to vape, but the facility had not documented this in the care plan or completed the required assessment at the time of the survey. These deficiencies were identified through observation, interviews, and record reviews, which revealed lapses in following established policies and care plan interventions. The facility did not ensure that residents at risk for falls or those using tobacco products were adequately supervised or assessed, leading to preventable incidents and a lack of appropriate care planning.
Failure to Provide Ongoing Assessment and Monitoring for Dialysis Resident
Penalty
Summary
The facility failed to provide ongoing assessment and monitoring for a resident who required dialysis services. According to the facility's own policy, staff are required to assess the resident's condition and monitor for complications before and after dialysis treatments, including checking vital signs, weight, and the status of the dialysis access site. However, review of the resident's medical record revealed that there was no documentation of comprehensive assessments, such as vital signs, weight, or inspection of the dialysis port site, either before or after the resident returned from dialysis. The medication and treatment administration records only showed weekly vital signs and weights, with no specific documentation related to pre- and post-dialysis care. Interviews with the resident and the Director of Nursing confirmed that staff did not consistently perform or document assessments upon the resident's return from dialysis. The resident reported that staff sometimes checked vital signs after dialysis, but not always immediately upon return. The DON acknowledged that staff did not document assessments after dialysis and that there was no established process for assessing the dialysis port site upon return, as some dialysis facilities preferred the bandage not be removed. The lack of ongoing assessment and monitoring was not consistent with the facility's policy or the resident's care plan.
Infection Control Lapses in Hand Hygiene, PPE Use, and Catheter Bag Management
Penalty
Summary
Facility staff failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene, use of personal protective equipment (PPE), and proper handling of medical devices. During wound care for a resident with multiple pressure injuries and diabetic foot ulcers, a registered nurse did not perform hand hygiene at required intervals, failed to use a gown as part of enhanced barrier precautions (EBP), and used personal supplies without proper disinfection. The nurse also placed contaminated items back into personal storage and did not sanitize equipment after use, contrary to facility policy and infection control standards. In another instance, a certified nursing assistant (CNA) did not perform hand hygiene after removing gloves during incontinence care for a resident, instead proceeding to handle clean items and assist with dressing without sanitizing hands. The CNA acknowledged the lapse when questioned and confirmed that hand hygiene should have been performed between glove changes, as required by facility policy. Additionally, a resident with an indwelling urinary catheter was repeatedly observed with the catheter bag lying on the floor, despite facility policy stating that drainage bags should not touch the floor. Staff were seen handling the bag and placing it back on the floor, and the resident reported that the bag was always on the floor. The care plan for this resident did not address proper placement of the urinary collection bag, and staff interviews confirmed the expectation that the bag should be kept off the floor.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to its policies regarding the storage, labeling, and dating of food items, which are essential to prevent foodborne illnesses. During a survey, multiple unlabeled and potentially expired food items were found in the facility's walk-in refrigerator and resident kitchenette. These included containers of Italian dressing, relish, whipping cream, milk, sour cream, and various dressings, some of which lacked open date labels or had expired manufacturer's dates. The Dietary Manager (DM) and Dietary staff admitted to not labeling items with open dates and acknowledged the presence of expired items. The surveyor observed that the facility's policy required all refrigerated and prepared food to be covered, labeled, and dated with a use-by date. However, this policy was not consistently followed, as evidenced by the presence of unlabeled and expired food items. The DM indicated that it was the responsibility of the kitchen staff to monitor the resident fridge, but this was not being done effectively. The DM also mentioned that nursing staff were expected to monitor the fridge, but this was not occurring, leading to expired food items being stored in the resident refrigerator. The Nursing Home Administrator (NHA) was unaware of any foodborne illnesses among staff and residents, but acknowledged the deficiency after being informed by the DM. The DM admitted to the NHA that items in the kitchen were not labeled with open dates and that expired items were found in the kitchen area. This lack of adherence to food safety protocols posed a risk of foodborne illness to the residents, although no illnesses were reported at the time of the survey.
Failure to Convey Deceased Resident's Trust Funds
Penalty
Summary
The facility failed to ensure the timely conveyance of a deceased resident's trust funds to the appropriate party. Specifically, the facility did not return the trust funds of a resident, identified as R1, to the Power of Attorney (POA) or family within 30 days of the resident's death. The facility's policy on Resident Trust Accounts mandates that upon a resident's death, the facility must promptly convey the resident's funds and provide a final accounting to the individual administering the resident's estate. However, a review of R1's account history revealed a positive balance of $180.11, with no documentation of funds being conveyed to the POA. During the survey, a family member of R1, identified as FM C, reported that the facility refused to refund the trust account balance, citing an outstanding balance of $5,000 owed by FM C. The Nursing Home Administrator (NHA) expressed uncertainty about the remaining balance, while the Accounts Receivable Specialist claimed that all trust accounts are typically conveyed within 30 days of discharge or death. Despite this assertion, the funds had not been returned, indicating a lapse in the facility's adherence to its policy and regulatory requirements.
Failure to Report Falls to Physician
Penalty
Summary
The facility failed to immediately report falls to the physician for two residents, leading to a deficiency in communication and care. The first resident, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite being found on the floor and examined for injuries, there was no documentation that the physician or family members were notified of the incident. An investigation later revealed that the nurse on duty did not inform the necessary parties, resulting in disciplinary action against the nurse. The second resident, with diagnoses including dementia and repeated falls, had two unwitnessed falls on 10/09/24 and 10/24/24. There was no documentation of physician notification for either incident. The Director of Nursing (DON) was unaware of the falls until observing the resident with facial bruising. The lack of documentation and communication with the physician regarding the resident's injuries and falls highlights a significant lapse in following the facility's change in condition policy.
Failure to Conduct Proper Assessments After Falls
Penalty
Summary
The facility failed to provide care and treatment according to professional standards of practice for two residents following falls. Resident 1, who had severe cognitive impairment and was at risk for falls, experienced a fall on 09/09/24. The resident was found on the floor tangled in bedding, but the nurse did not perform a thorough assessment, including vital signs, neurological checks, or a head-to-toe examination. The fall was not reported to hospice services or the family until the following day when the resident showed signs of pain and bruising, indicating a possible injury. Resident 2, diagnosed with dementia and at risk for falls, had an unwitnessed fall and another incident where they slid out of a wheelchair. Despite these events, there was no documentation of a comprehensive assessment, including vital signs or neurological checks, in the resident's records. The Director of Nursing was unaware of the falls until observing the resident with facial bruising, suggesting a lack of communication and documentation by the nursing staff. The facility's failure to conduct proper assessments and communicate falls to relevant parties resulted in deficiencies in maintaining the residents' highest practicable level of physical well-being. The lack of documentation and communication highlights a significant gap in the facility's fall management protocol, as outlined in their policy, which requires thorough assessments and timely reporting of falls to physicians and family members.
Failure to Implement Post-Fall Interventions
Penalty
Summary
The facility failed to implement new care planned fall interventions for three residents who were at risk for falls. Resident 1, diagnosed with Alzheimer's disease and other conditions, experienced a fall on 09/09/24. Despite a discussion on 09/11/24 to add a fall mat as a new intervention, this was not added to the care plan, and no other interventions were updated following the fall. Resident 2, with diagnoses including dementia and repeated falls, had two falls on 10/09/24 and 10/24/24. The facility did not implement any new interventions after these incidents, despite the resident's care plan being in place since 04/22/24. The care plan included various interventions, but none were updated or added following the falls. Resident 3, who had a history of falling and other medical conditions, fell on 10/21/24. The care plan, initiated in 2018, was not updated with new interventions after the fall. The Director of Nursing acknowledged that no new interventions were implemented for any of the residents after their falls, citing that staff sometimes miss implementing new interventions.
Improper Hand Hygiene and Hair Net Use in Food Service
Penalty
Summary
The facility did not ensure proper hand hygiene and use of hair nets in accordance with professional standards for food service safety. During an initial walkthrough of the kitchen, a Certified Nursing Assistant (CNA) was observed entering the kitchen without wearing a hair net, despite a sign indicating that hair nets were required. The CNA indicated they were just grabbing coffee, but their uncovered hair could easily fall into the coffee cup, which was located near the cooking and plating areas of the kitchen. Additionally, during the point of service plating before lunch, a Dietary Cook (DC) was observed using gloves to place bread on residents' plates. However, the DC touched their glasses and stove controls without changing gloves or using hand hygiene before continuing to handle the bread. The Dietary Manager (DM) confirmed that they would expect anyone entering the kitchen to wear a hair net and that staff should use tongs or change gloves and wash hands if unclean items are touched during the serving process.
Failure to Schedule Follow-Up Oncology Appointment
Penalty
Summary
The facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to follow physician orders to schedule a follow-up oncology appointment within 2-4 days after admission for a resident diagnosed with a lesion on the left ninth rib, which could represent metastatic disease. The hospital discharge summary clearly indicated the need for this follow-up, but the facility did not act on these orders in a timely manner. The facility's admission checklist required multiple checks and signatures to ensure all orders were followed, but this process was not effectively executed. The Social Services Assistant, responsible for scheduling appointments, did not receive the necessary information to schedule the oncology follow-up. Interviews with staff, including the DON and RN, revealed that the facility's procedure for scheduling appointments was not followed, and there was confusion about the responsibility for ensuring the appointment was made. The resident confirmed awareness of the oncology referral but was unsure if the appointment had been scheduled. The DON and other staff members acknowledged the oversight and indicated that the facility was waiting for insurance authorization, which had not been communicated effectively. There was no documentation of attempts to schedule the appointment or communicate with other providers until the surveyor's review, indicating a lapse in the facility's protocol and communication processes.
Failure to Supervise Resident During Use of Oscillating Percussion Vest
Penalty
Summary
The facility did not evaluate for hazards or risks related to the use of an oscillating percussion vest for a resident with quadriplegia and a high risk for aspiration. The resident, who has a history of aspiration pneumonia and other severe medical conditions, was observed alone in his room wearing the vest without supervision. The care plan did not address whether the resident was safe to be left alone with the vest or how supervision would be provided during the treatment sessions. Staff interviews revealed that the resident was unable to use a call light to ask for assistance, and there was no clear protocol for ensuring the resident's safety during the vest treatment. The resident's physician orders included the use of the Afflo Respiratory Vest twice daily while sitting up in a wheelchair, with specific instructions to stop tube feeding during the session and check the resident's mouth and lung sounds afterward. However, observations and staff interviews indicated that these orders were not consistently followed. For instance, the surveyor did not observe nursing staff checking the resident's lung sounds after a vest session, and the resident had a large amount of mucus in his mouth that required oral care. The Director of Nursing (DON) confirmed that the resident's care plan did not initially include the use of the chest vest and that an assessment to determine if the resident was safe to wear the vest unsupervised had not been conducted. Despite the manufacturer's instructions indicating that disabled persons should not use the vest without supervision, the facility did not have a clear protocol for supervising the resident during vest treatments. Staff reported that they usually kept the resident by the nurse's station or left his door open for observation, but this was not documented in the care plan or consistently practiced.
Improper Verification of G-Tube Placement During Medication Administration
Penalty
Summary
The facility did not ensure that residents who are medicated by enteral means received the appropriate treatment to prevent complications during medication administration through a Gastric tube (G-tube). This was observed with one resident who received medication without ensuring the G-tube was appropriately placed prior to medication administration. The resident, who had diagnoses of epilepsy, cerebral palsy, and functional intestinal disorder, was observed receiving valproic acid via G-tube without proper verification of tube placement according to current standards of practice. The Licensed Practical Nurse (LPN) administering the medication used an outdated method of injecting air into the G-tube and listening for noise to check for proper placement. This method is no longer the standard of practice, as confirmed by the surveyor and the Director of Nursing (DON). The facility's policy, last revised in March 2020, still included this outdated practice, leading to the deficiency observed during the survey.
Infection Control Deficiencies
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Staff failed to perform proper hand hygiene during medication administration with a resident who had a severe cognitive impact. Specifically, a registered nurse did not perform hand hygiene before and after administering medications to the resident and proceeded to check another resident's blood sugar without proper hand hygiene initially. This was observed by a surveyor and confirmed by the Director of Nursing, who acknowledged that the nurse should have performed hand hygiene between residents. Additionally, the facility prematurely removed droplet precautions for a resident who tested positive for COVID-19. The resident was supposed to remain on droplet precautions for ten days following the onset of symptoms, but staff miscounted the isolation days, leading to the removal of precautions one day early. This error was identified when the surveyor observed the resident on contact precautions instead of droplet precautions. The Assistant Director of Nursing confirmed that the miscalculation occurred because staff did not count the first day of isolation as day zero, resulting in the premature removal of droplet precautions.
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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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