Meadowbrook At Oconto Falls
Inspection history, citations, penalties and survey trends for this long-term care facility in Oconto Falls, Wisconsin.
- Location
- 100 E Highland Dr, Oconto Falls, Wisconsin 54154
- CMS Provider Number
- 525449
- Inspections on file
- 28
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Meadowbrook At Oconto Falls during CMS and state inspections, most recent first.
Surveyors found that two cognitively intact residents who smoked or vaped were allowed to keep and use their smoking and vaping materials contrary to facility policy and their care plans. One resident with quadriplegia, COPD, diabetes, anxiety, and nicotine dependence kept multiple vaping devices in the room and reported frequent in‑room vaping, despite a care plan and Safe Smoking Evaluation requiring materials to be stored at the nurses’ station and use only in designated areas. Staff, including a CNA, an LPN, and a medication technician, acknowledged awareness of the resident’s in‑room vaping and that the resident turned in only empty devices, while the smoking materials lock box contained none of the resident’s items. Another resident with acute kidney failure, diabetes, and nicotine dependence kept cigarettes and a lighter in the room and on their person, walked past staff with cigarettes, and smoked outside after leaving the building, despite a care plan requiring smoking materials to be turned in between use. Staff interviews confirmed that this resident usually retained smoking materials, that there was no consistent follow‑up to ensure storage in the lock box, and that the lock box did not contain the resident’s materials, in conflict with the facility’s Safe Smoking/Tobacco Use Policy.
A resident with severe cognitive impairment was not protected from abuse by another resident with a history of inappropriate sexual behavior. The incident occurred in the dining room, and despite being reported, the facility failed to assess the vulnerable resident for injury or implement supervision measures. Staff interviews revealed inconsistent documentation and communication regarding the incident and the residents' behaviors.
A resident with severe cognitive impairment and behavioral disturbances frequently wandered into other residents' rooms, causing distress and fear. Despite multiple residents reporting grievances about this behavior, the facility failed to document or resolve these concerns effectively. Staff were aware of the behavior but did not implement effective interventions, and the facility's grievance policy was not followed, leaving residents' concerns unaddressed.
A facility failed to report an alleged sexual abuse incident involving a resident with severe cognitive impairment. The incident, witnessed by another resident, was not reported to the State Agency as required by the facility's policy. The leadership team decided against reporting, citing a lack of intent from the alleged perpetrator.
A facility failed to report and thoroughly investigate an alleged sexual abuse incident involving two residents. Despite a guardian's report of one resident fondling another, the facility did not notify authorities or conduct a timely investigation. Discrepancies in staff statements and delayed resident interviews further highlighted the facility's inadequate response.
A resident with severe dementia and behavioral disturbances was inadequately supervised and lacked an updated care plan, leading to safety concerns. The resident frequently wandered and exhibited aggressive behaviors, such as yelling and biting, which were not effectively managed by the facility. Despite receiving medications, there were no adjustments made, and staff interventions were often ineffective, resulting in a deficiency in providing a safe environment.
The facility failed to update care plans for four residents, leading to deficiencies in addressing their needs and concerns. A resident with severe cognitive impairment frequently called out, but their care plan lacked interventions to manage this behavior. Two other residents expressed concerns about the noise, but their care plans did not include coping strategies. Additionally, a resident's care plan was not updated to reflect changes in supervision needs, causing confusion during an altercation.
Two residents expressed concerns about a neighboring resident frequently calling out, but the facility failed to document or resolve their grievances. Despite attempts to manage the behavior of the resident causing the disturbance, the affected residents were not provided with effective solutions, and their complaints were not escalated or formally recorded, violating the facility's grievance policy.
A resident with hemiplegia and hemiparesis fell out of a Hoyer lift during a transfer conducted by a CNA alone, contrary to the care plan requiring two staff. The resident experienced significant pain and a delayed diagnosis of a left hip fracture due to inadequate assessment and investigation by the facility staff.
The facility failed to ensure an RN was on duty for at least 8 consecutive hours per day, 7 days per week. There was no RN on duty from 6:05 PM on 5/17/24 until 12:00 PM on 5/19/24. The DON confirmed the scheduled RN did not come in, and although the DON worked on 5/19/24, they did not punch in and out on the time clock.
The facility failed to maintain an effective infection prevention and control program, with incomplete infection surveillance logs and staff not adhering to proper infection control practices. A Laundry Aide entered a resident's isolation room without PPE, and an LPN did not perform hand hygiene after glove removal. Another LPN used scissors on a resident's wound without disinfecting them between uses, violating equipment protocol.
The facility failed to ensure complete informed consent for medications for four residents, including psychotropic drugs. Consent forms lacked necessary information such as dosage ranges and alternative treatments, and were not properly initialed and dated. The DON confirmed these deficiencies, highlighting a lapse in ensuring residents or their representatives were fully informed about medication risks and benefits.
The facility did not ensure that the PCV20 vaccine was reviewed, offered, and administered to four residents with significant medical histories, despite CDC recommendations. The Infection Preventionist acknowledged the oversight and had not audited or offered the vaccine to existing residents.
The facility failed to maintain mechanical lift equipment safely, affecting 17 residents. Observations showed wear and tear, with issues like rust, hair in wheels, and broken emergency pulls. Residents and CNAs reported feeling unsafe, with lifts described as old and slow. Maintenance inspections did not note concerns, and a list of repairs was not provided. The facility was ordering parts to address issues.
A resident with a pressure injury on the left heel was not provided with the necessary care to prevent further breakdown, as staff failed to ensure the resident wore a heel boot as prescribed. The care plan and Kardex were not updated to reflect the intervention, and CNA staff were unaware of the requirement. The resident had moderately impaired cognition and was admitted with multiple diagnoses, including multiple sclerosis and osteoarthritis.
Two residents with indwelling catheters were observed with uncovered drainage bags in contact with the floor, contrary to the facility's policy and infection control practices. The facility's catheter policy requires bags to be covered, but does not address proper positioning. Staff confirmed the bags should not be on the floor, highlighting a lapse in adherence to infection prevention protocols.
The facility failed to provide adequate respiratory care and monitoring for three residents. A resident used oxygen therapy without a physician's order, and their care plan did not address this therapy. Two residents on droplet and contact precautions lacked consistent monitoring for respiratory symptoms. The facility's policies on oxygen use and isolation precautions were not properly followed, leading to these deficiencies.
A facility failed to maintain a signed and dated contract with the correct dialysis center for a resident requiring dialysis services. The resident, with end-stage renal disease, received treatment at an outside center three times weekly. The contract had incorrect names and lacked a date and signature page. The DON explained a merger caused the discrepancy, but the facility could not provide the necessary documentation.
A resident with diabetes did not receive timely administration of Fiasp insulin due to a delay of over an hour between the blood sugar check and insulin administration. The LPN failed to educate the resident on the importance of accurate dosing based on current blood sugar levels, leading to a deficiency in pharmaceutical services.
A resident prescribed mirtazapine for depression was not monitored for adverse reactions or effectiveness, as their care plan lacked necessary interventions. The resident, with intact cognition and responsible for their healthcare decisions, was admitted with multiple injuries. The deficiency was confirmed by the DON.
A long-term care facility experienced a 20% medication error rate during observations, affecting three residents. Errors included incorrect doses of Miralax, vitamin B-complex, vitamin B12, and a multivitamin. An LPN admitted to the mistakes, and the Director of Nursing confirmed these as medication errors.
Failure to Enforce Smoking and Vaping Safety Policies for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident environment as free of accident hazards as possible and to provide adequate supervision related to smoking and vaping for two cognitively intact residents. Facility policy, revised 1/2026, states that smoking is not permitted in the facility or where oxygen is in use, that residents who smoke or use e‑cigarettes must be evaluated for safe or unsafe use, and that staff are to maintain all smoking materials, including e‑cigarettes, as appropriate for the resident. The policy further requires that smoking, smokeless tobacco use, and e‑cigarette use occur only in designated locations that are environmentally separate from resident care areas, and that staff maintain smoking materials in a secure area such as the nurses’ station, distributing them only at smoking times or via a locked container for residents deemed safe. One resident (R1), with diagnoses including quadriplegia, COPD, diabetes, anxiety, and nicotine dependence, had a BIMS score of 15/15 and was responsible for their own medical decisions. R1’s care plan documented that the resident chose to vape, was to vape only in designated areas, and was to turn in smoking materials when not smoking, with encouragement to leave all smoking items at the nurses’ station. The care plan also documented that R1 was non‑compliant with the smoking policy and had been observed vaping in the room, and that a risk versus benefits form had been completed because R1 continued to vape in the room. A Safe Smoking Evaluation dated 3/4/26 indicated R1 had been informed that all smoking materials must be secured at the nurses’ station or other designated area when not in use and that R1 must request smoking materials from staff. Despite this, the surveyor observed two vaping devices in R1’s room, including one plugged into a computer, and R1 reported vaping in the room at night and in the morning, approximately 10 to 20 times or more per hour, keeping the devices in the room and using them inside the facility. Multiple staff confirmed awareness of R1’s in‑room vaping and the presence of vaping devices. A CNA stated staff and management were aware that R1 had and used the devices in the room. An LPN reported knowing that R1 vaped in the room and that the DON had previously been involved in a contract for R1 to store vaping materials at the nurses’ station, but that R1 had been openly vaping for a long time and had turned in only empty devices while keeping usable ones. A medication technician also knew R1 had vaping devices in the room and stated R1 turned in used, non‑working devices while keeping functional ones. When the surveyor and the medication technician checked the smoking materials lock box, there were no materials for R1, contrary to the care plan and policy requirements. A second resident (R2), with diagnoses including acute kidney failure, diabetes, and nicotine dependence on cigarettes, also had a BIMS score of 15/15 and was responsible for their own medical decisions. R2’s care plan stated that the resident chose to smoke cigarettes, would smoke only in designated areas, and would turn smoking materials into nursing staff for safekeeping between smoking, with re‑evaluation if safety became a concern. A Safe Smoking Evaluation indicated R2 had been informed of the evaluation results. However, the surveyor observed R2 in the room holding a pack of cigarettes, then placing the cigarettes in a pocket, passing the nurses’ station with staff present, exiting the building, and lighting a cigarette. R2 initially denied keeping smoking materials in the room but then admitted doing so and stated that once cigarettes were picked up in the morning, they were kept by the resident. Staff interviews confirmed that R2 routinely retained smoking materials instead of turning them in as required. A CNA stated R2 usually kept cigarettes and a lighter for convenience and did not return them to the nurses’ station. The LPN acknowledged knowing that R2 kept smoking materials and stated that, although materials were supposed to be stored in a lock box behind the nurses’ station, there was no follow‑up or consistency, so R2 and other residents kept their materials. The medication technician reported being aware that R2 kept cigarettes and lighters and believed R2 was not a supervised smoker and could keep these items, also noting that R2 often obtained cigarettes from other residents. When the surveyor and medication technician checked the smoking materials lock box, there were no materials for R2. The DON stated that staff and residents should follow the smoking policy and that staff were supposed to keep R1 and R2’s smoking materials, which should not be kept on their person or in their rooms, and reported not being aware that R1 kept vaping materials in the room or vaped in the room.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident with severe cognitive impairment who was vulnerable due to wandering unsupervised. This deficiency involved a resident with a history of sexually inappropriate behavior who allegedly groped the vulnerable resident in the dining room. Despite the incident being reported to the Nursing Home Administrator, the vulnerable resident was not assessed for injury, and no interventions were put in place to supervise the residents involved. The facility's staff did not adequately document or investigate the incident. The medical records of the involved residents did not reflect the alleged sexual assault or any subsequent assessments. Interviews with staff revealed a lack of consistent communication and documentation regarding the incident and the residents' behaviors. The staff's accounts varied, with some indicating that the inappropriate behavior was ongoing and not effectively managed. The facility's policies on abuse prevention and resident protection were not followed, as evidenced by the lack of immediate investigation and protective measures. The failure to supervise the resident with a history of inappropriate sexual behavior and the vulnerable resident who wandered unsupervised created a situation of immediate jeopardy, which was not addressed until much later. The facility's inaction and inadequate response to the incident contributed to the deficiency.
Removal Plan
- Initiated one-to-one supervision for R9 who will be at least arms-length from and not seated near female residents.
- Updated R9's behavior care plan and implemented interventions in accordance with R9's behavior patterns.
- Consulted with R9's providers for suggestions and interventions.
- Educated staff on abuse, behavior documentation, and updated care plan interventions.
Failure to Address Resident Grievances Regarding Wandering Behavior
Penalty
Summary
The facility failed to acknowledge and resolve grievances related to a resident, R2, who exhibited wandering behavior and entered other residents' rooms uninvited. R2, diagnosed with severe cognitive impairment and behavioral disturbances, was known to wander into rooms, rummage through belongings, and exhibit aggressive behavior. Despite multiple residents, including R3, R4, R6, R7, and R8, expressing concerns about R2's behavior, the facility did not document these grievances or implement effective interventions to prevent R2 from entering their rooms. R3 filed a formal grievance after R2 entered R3's room and rummaged through belongings, but the facility did not follow up or resolve the issue. R4, R6, R7, and R8 also reported R2's unwelcome presence in their rooms, with R4 describing a specific incident where R2 blocked the exit and acted aggressively. Despite these reports, the facility did not document these concerns as grievances or take action to prevent further incidents. Staff interviews revealed that R2's behavior was known, but interventions such as redirection were ineffective, and no new strategies were implemented. The facility's grievance policy requires that all concerns be documented and addressed promptly, but this was not adhered to in the case of R2's behavior. The Nursing Home Administrator and Director of Nursing were unaware of the extent of the grievances and did not take appropriate action to address the residents' concerns. The lack of documentation and follow-up on these grievances highlights a failure in the facility's grievance process, leaving residents feeling unsafe and their concerns unaddressed.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident, R2, to the State Agency (SA) as required by their Abuse Prevention Program policy. The incident occurred when R9 allegedly groped R2's breast in the cafeteria, witnessed by R10, who reported the incident to R2's guardian and the Nursing Home Administrator (NHA). Despite the report, the facility's leadership, including the Director of Nursing (DON), NHA, Chief Nursing Officer (CNO), and Regional Director of Operations (RDO), decided not to report the incident to the SA, citing a lack of intent from R9 as the reason. R2, who has severe cognitive impairment due to non-Alzheimer's dementia, was unable to advocate for themselves, and the incident was brought to light by R10 and R2's guardian. R10, who is cognitively intact, witnessed the incident and attempted to intervene before staff moved R9 away from R2. The facility's policy mandates immediate reporting of abuse allegations to regulatory agencies, but this protocol was not followed, as the leadership team concluded that the incident was not reportable. This decision was made despite the clear policy requirements and the serious nature of the allegation.
Failure to Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the State Agency. On 10/23/24, a guardian reported that a resident fondled another resident's breast in the dining room. Despite the report, the facility did not conduct a thorough investigation or notify the appropriate authorities as required by their Abuse Prevention Program policy. The policy mandates that all incidents, whether or not abuse is confirmed, should be documented and investigated, and that local law enforcement should be contacted in cases of intentional sexual touching. The incident involved a resident with severe cognitive impairment and a guardian as the decision-maker, and another resident who was not cognitively impaired. The guardian and another resident witnessed the incident and reported it to the facility staff, but the Nursing Home Administrator (NHA) did not initiate an investigation until prompted by the guardian the following day. The NHA reviewed video footage but denied the guardian's requests to view it, and the facility did not report the incident to the police. The guardian expressed dissatisfaction with the facility's handling of the incident and the care provided to the resident. Discrepancies were noted in the statements from staff members regarding the incident, and the facility's documentation was inconsistent. The NHA's notes indicated that the incident did not involve abuse, and the guardian was reportedly fine with this determination, although this was contradicted by the guardian's statements. Additionally, the facility failed to conduct a skin assessment for the resident involved, and resident interviews to ensure safety and freedom from abuse were not completed until several weeks after the incident.
Inadequate Supervision and Care Planning for Resident with Dementia
Penalty
Summary
The facility failed to ensure appropriate supervision and care planning for a resident with severe dementia and behavioral disturbances, leading to safety concerns for the resident and others. The resident, identified as R2, exhibited wandering behavior and was physically and verbally aggressive. Despite these behaviors, the facility did not revise R2's care plan to include effective behavioral and monitoring interventions. The care plan initially included goals to prevent R2 from leaving the facility unattended and to prevent harm to R2 or others, but it lacked updates to address the resident's increasing behavioral issues. Observations and interviews revealed that R2 frequently wandered into other residents' rooms and exhibited aggressive behaviors such as yelling, hitting, and biting. Staff members, including CNAs and nurses, reported that R2's interventions, such as redirecting and providing a baby doll, were often ineffective. The facility's Dementia Care policy required individualized care plans and monitoring by a behavior committee, but there was no evidence that R2's care plan was updated or that the physician was notified of the resident's frequent and severe behaviors. The surveyor's review of R2's medical and treatment records indicated that the resident received medications for anxiety and dementia, but there were no adjustments made despite the increased frequency of behaviors. Interviews with staff confirmed that R2's behaviors were not effectively managed, and the resident continued to pose a risk to themselves and others. The facility's failure to implement and document appropriate interventions and supervision for R2 resulted in a deficiency in providing a safe environment for all residents.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to ensure that care plans were updated for four residents, leading to deficiencies in addressing their needs and concerns. Resident 3, who had severe cognitive impairment and frequently called out, did not have an updated care plan to reflect this behavior or include interventions to manage it. Despite multiple progress notes indicating the resident's vocalizations and the administration of medications like lorazepam and tramadol, the care plan lacked specific strategies to address the calling out behavior. Interviews with staff revealed that interventions such as changing the resident's position or environment were used, but these were not documented in the care plan. Residents 4 and 5, who were cognitively intact, expressed concerns about the frequent calling out by Resident 3, which affected their well-being. However, their care plans did not include interventions to assist them in coping with the disturbances. Resident 5, who suffered from claustrophobia, was not offered alternatives like a sound machine, and Resident 4 reported feeling more short-tempered due to the noise. The social worker acknowledged the importance of having care plan interventions for these residents but noted that they were not in place. Resident 2's care plan was not updated to reflect changes in supervision needs, leading to confusion during an altercation with another resident. Initially on 1:1 supervision, the care plan was not revised to indicate the current level of supervision, resulting in uncertainty among staff about the required checks. Interviews with nursing staff revealed a lack of clarity regarding the supervision level, which contributed to the incident. The Director of Nursing confirmed that care plans should be updated with any changes in a resident's plan of care.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances for two residents, R4 and R5, who expressed concerns about another resident, R3, frequently calling out. Despite the facility's policy requiring grievances to be documented and addressed, no grievance forms were completed for R4 and R5. Both residents had intact cognition and reported their concerns to multiple staff members, but their grievances were not formally recorded or resolved. R3, who had severely impaired cognition due to a stroke, frequently called out, causing distress to neighboring residents. Medical interventions, including medication adjustments, were attempted to address R3's behavior, but these efforts were not communicated effectively to R4 and R5. R5 reported difficulty sleeping due to R3's behavior and was not offered any solutions other than closing the door, which was not feasible due to claustrophobia. R4 also expressed frustration with the ongoing disturbances and felt that nothing had been done to address the issue. Staff members, including a CNA and an LPN, acknowledged the concerns raised by R4 and R5 but did not escalate the grievances to the Director of Nursing or complete the necessary documentation. The Social Worker was aware of the concerns and sought guidance from the Ombudsman but did not fill out grievance forms for R4 and R5. This lack of documentation and follow-through resulted in the facility's failure to honor the residents' right to voice grievances and ensure prompt resolution, as required by their policy.
Failure to Ensure Safe Transfer Procedures
Penalty
Summary
The facility did not ensure a safe environment free from accident hazards for a resident who fell out of a Hoyer lift during a transfer conducted by a CNA alone. The resident, who had a history of hemiplegia and hemiparesis following a stroke, reported the fall to staff the following day and was later diagnosed with a left hip fracture. The resident's care plan indicated the need for a full mechanical lift with the assistance of two staff for all transfers, which was not followed during the incident. The facility's investigation revealed that the CNA used a sit-to-stand lift and a Hoyer lift alone to transfer the resident, contrary to the care plan requirements. The resident experienced significant pain following the fall, which was not adequately assessed by the staff, leading to a delay in diagnosis and treatment. The resident's medical record showed multiple requests for pain relief, and the resident expressed a desire to go to the emergency room, which was initially dismissed by the staff. Interviews with various staff members and a review of the facility's camera footage confirmed that the CNA did not follow proper transfer protocols and that the incident was not promptly reported or investigated. The Director of Nursing and other staff members failed to conduct a thorough assessment and investigation immediately after the resident reported the fall, resulting in a delay in addressing the resident's pain and injury. The facility's policies on change of condition and abuse prevention were not adequately followed, contributing to the deficiency in providing a safe environment for the resident.
Failure to Ensure RN Coverage
Penalty
Summary
The facility did not ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days per week, as required. This deficiency was identified through staff interviews and record reviews. Specifically, there was no RN on duty from 6:05 PM on 5/17/24 until 12:00 PM on 5/19/24. The facility's assessment, revised on 5/14/24, indicated that an RN would be on duty as required, but this was not adhered to. The facility did not have a waiver related to staffing or having an RN on duty. The Director of Nursing (DON) confirmed that the RN scheduled for the weekend did not come in, and although the DON worked on 5/19/24 from approximately 12:00 PM to 8:00 PM, they did not punch in and out on the time clock.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews conducted by surveyors. The facility did not maintain an infection tracking and surveillance log, which is crucial for detecting disease transmission patterns. The Infection Preventionist admitted to being behind on documentation, resulting in incomplete and inaccurate records for April 2024. This oversight had the potential to affect all 50 residents in the facility, as timely and accurate documentation is essential for monitoring and controlling infections. In addition to documentation issues, staff members were observed not adhering to proper infection control practices. A Laundry Aide entered a resident's room, which was under contact and droplet precautions, without donning the required personal protective equipment (PPE) or performing hand hygiene. This action was contrary to the facility's policy and the expectations of the Director of Nursing, who confirmed that all staff, including laundry personnel, should follow PPE guidelines when entering isolation rooms. Further deficiencies were noted in the provision of care by nursing staff. An LPN failed to perform hand hygiene after removing gloves during a blood sugar check for a resident, which is a critical step in preventing cross-contamination. Another LPN used scissors to cut a soiled dressing and then a clean dressing for a resident's wound without disinfecting the scissors in between, violating the facility's equipment protocol. These actions demonstrate a lack of adherence to established infection control procedures, potentially compromising resident safety.
Incomplete Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents or their legal representatives were fully informed and understood the risks and benefits of prescribed medications, as required by their own policy and state regulations. This deficiency was identified for four residents who were prescribed various medications, including psychotropic drugs. The informed consent forms for these medications were incomplete, lacking necessary information such as anticipated dosage ranges, alternative treatments, and probable consequences of not receiving the medication. Additionally, the forms were not properly initialed and dated by the residents or their representatives. One resident, with intact cognition, was prescribed mirtazapine but the consent form was missing critical information and was not fully completed. Another resident, with severely impaired cognition, had a Power of Attorney for Healthcare (POAHC) responsible for their decisions. The POAHC signed consent forms for multiple medications, but these forms were incomplete and not properly initialed or dated. A third resident, also with severely impaired cognition, had a consent form for quetiapine that was not fully completed, and the resident did not initial or date the form as required. The fourth resident, with intact cognition, was prescribed several medications with black box warnings. The consent forms for these medications were signed but not properly initialed and dated. The Director of Nursing confirmed the deficiencies in the consent forms for all four residents, acknowledging the importance of complete and accurate documentation for informed consent.
Failure to Administer PCV20 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that vaccinations were reviewed, offered, and administered to four residents, specifically the PCV20 vaccine, as per the CDC recommendations. The residents involved were R17, R18, R20, and R23, each with significant medical histories including chronic kidney disease, multiple sclerosis, cancer, and pneumonia, respectively. Despite having received previous pneumococcal vaccinations (PPSV23 and PCV13), there was no indication in their medical records that they were offered or administered the PCV20 vaccine. The deficiency was identified during a survey where the Infection Preventionist (IP)-C acknowledged that residents should be offered the PCV20 vaccine upon admission. However, IP-C admitted to not having audited or offered the PCV20 vaccine to existing residents. This oversight was noted during an interview with the surveyor, where IP-C mentioned working with regional support to develop a process for monitoring PCV20 vaccinations.
Deficiency in Mechanical Lift Maintenance
Penalty
Summary
The facility failed to maintain mechanical lift equipment in a safe operating condition, affecting 17 residents who relied on these lifts for transfers. Observations and interviews revealed that the lifts showed signs of wear and tear, with issues such as rust-like substances on the legs and wheels, hair caught in the wheels, and duct tape on handles. Additionally, the emergency pull on one of the lifts was broken, and the lifts were described as old, slow, and unsafe by both residents and staff. Two residents, both with intact cognition, expressed concerns about the lifts. One resident reported feeling unsafe and experiencing pain due to the slow operation of the lifts, while another resident mentioned the lifts were old and did not work well. Certified Nursing Assistants (CNAs) also expressed concerns, noting that the lifts were rickety, wobbly, and had issues with the legs spreading during transfers. The emergency pull on a stand lift was demonstrated to be non-functional, causing discomfort to residents. The Maintenance Supervisor stated that lifts were inspected monthly, but acknowledged issues with battery life and the emergency pull on one lift. Despite monthly inspections, the inspection sheets did not note any concerns, and a list of repair requests was not provided. The Director of Nursing confirmed swapping an older lift with a newer one for a resident's transfer after concerns were raised, but was unaware of other residents' concerns. The facility was in the process of ordering parts to address the shifting legs of the lifts.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of or promote healing for a resident with a pressure injury. The resident, who had a pressure injury on the left heel, was observed on multiple occasions not wearing the prescribed heel boot while out of bed. The care plan for the resident was not updated to reflect the intervention of wearing a heel boot at all times except during walking and transfers. The CNA staff was unaware of the requirement for the resident to wear the heel boot during the day, as the intervention was not documented in the resident's Kardex or care plan. The resident, who had moderately impaired cognition, was admitted with diagnoses including multiple sclerosis, osteoarthritis, and a history of falling. Despite a wound note indicating a change in treatment to wearing a heel boot instead of a slipper, the staff failed to implement this intervention. The CNA followed the outdated Kardex and care plan, which did not include the updated order for the heel boot. The Director of Nursing confirmed that the care plan should have been updated and that staff should document if the resident refused to wear the heel boot.
Inadequate Catheter Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for two residents with indwelling catheters. The surveyor observed that the catheter drainage bags of these residents were uncovered and in contact with the floor, which is against the facility's policy and standard infection control practices. The facility's catheter policy mandates that catheter drainage bags should be covered at all times to maintain dignity and privacy, but it does not address the positioning or placement of tubing or drainage bags. The Relias training provided to nursing staff emphasizes the importance of keeping drainage bags off the floor to prevent contamination and infection. Resident 20, who has chronic kidney disease and moderately impaired cognition, was observed with an uncovered catheter drainage bag visible from the hallway and in contact with the floor. Similarly, Resident 18, who has multiple sclerosis and a history of urinary tract infection and inflammatory reaction due to a urinary catheter, was also observed with an uncovered catheter drainage bag in contact with the floor. Both the Certified Nursing Assistant and the Director of Nursing confirmed that the catheter bags should not be on the floor due to infection control issues, and that education on this matter is provided during various training sessions.
Deficiencies in Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide necessary respiratory care for three residents with respiratory needs. Resident 7 was observed using oxygen therapy without a physician's order, and their care plan did not address the use of oxygen therapy. Despite having standing orders for oxygen use, the facility did not activate these orders in Resident 7's medical record, nor did they initiate a care plan for the oxygen therapy. This oversight was confirmed by the Director of Nursing, who acknowledged that the standing orders should have been activated and a care plan should have been in place. Residents 12 and 2 were placed on droplet and contact precautions due to exposure to pneumonia. However, their medical records lacked consistent monitoring or assessments for respiratory symptoms. Resident 12's record showed only one pulse and temperature reading on two separate days, and Resident 2's record contained minimal documentation regarding respiratory status and the effectiveness of treatment. The Infection Preventionist confirmed that vital signs should be conducted every shift, although this requirement was not included in the facility's isolation precaution policy. The facility's policies on Liquid Oxygen Use and Isolation Precautions were not adequately followed, leading to deficiencies in the care provided to these residents. The Liquid Oxygen Use policy required physician orders for oxygen therapy and regular monitoring of oxygen saturation levels, which were not documented for Resident 7. Additionally, the Isolation Precautions policy lacked specific guidelines for symptom monitoring, contributing to the inadequate monitoring of Residents 12 and 2 during their precautionary period.
Incomplete Dialysis Contract for Resident
Penalty
Summary
The facility failed to ensure they had a signed and dated contract with the correct name of the dialysis center for a resident who required dialysis services. The resident, who had diagnoses including end-stage renal disease and acute renal failure, received hemodialysis at an outside dialysis center three times a week. Despite the facility's policy to ensure proper care and services for hemodialysis, the contract with the dialysis center was found to be inaccurate and incomplete. During the survey, it was discovered that the contract had the name of the original skilled nursing facility and dialysis center blacked out, with new names typed over them. The dialysis center named in the contract did not match the one in the resident's medical record. Additionally, the contract lacked a date and a signature page. The Director of Nursing explained that the current dialysis center and the one named in the contract had merged, which led to the discrepancy. However, the facility was unable to provide a signature page or documentation of the contract date.
Deficiency in Timely Insulin Administration
Penalty
Summary
The facility failed to ensure the timely administration of insulin for a resident with diabetes mellitus, leading to a deficiency in pharmaceutical services. The resident, who had intact cognition and was responsible for their healthcare decisions, was prescribed Fiasp, a short-acting insulin, with dosing based on blood sugar levels. On the morning in question, the resident's blood sugar was checked at 7:45 AM, showing a level of 199 mg/dl. However, the insulin was not administered until 8:57 AM, approximately 1 hour and 15 minutes later, which is beyond the recommended 30-minute window for administering short-acting insulin based on a sliding scale. The LPN involved did not provide the necessary education to the resident about the importance of obtaining a current blood sugar result for accurate dosing. Despite the resident declining a recheck of their blood sugar, the LPN proceeded to administer 28 units of Fiasp without ensuring the dose was accurate based on a current blood sugar reading. This oversight was confirmed during an interview with the LPN, who acknowledged the need for rechecking the blood sugar and educating the resident. The physician also confirmed that short-acting insulin should be administered within 30 minutes of a blood sugar check, highlighting the deficiency in the facility's pharmaceutical services.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to ensure proper monitoring for adverse reactions or the effectiveness of a psychotropic medication for one resident. The resident, who was admitted with multiple fractures and internal injuries following a motor vehicle accident, had a BIMS score indicating intact cognition and was responsible for their healthcare decisions. The resident was prescribed mirtazapine, an antidepressant, but their care plan lacked interventions for staff to monitor for adverse reactions or the medication's effectiveness. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the omission in the resident's care plan.
Medication Error Rate Exceeds 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 20% error rate during medication administration observations. This affected three residents, with errors occurring in the administration of Miralax, vitamin B-complex with folic acid, vitamin B12, and a multivitamin. One resident received only one-third of the prescribed dose of Miralax, while another was given incorrect doses and types of vitamin supplements. Additionally, a surveyor intervened to prevent the administration of an incorrect insulin dose. The errors were primarily attributed to the actions of an LPN who prepared and administered medications incorrectly. The LPN admitted to the mistakes during interviews with the surveyor, acknowledging the incorrect administration of medications and the preparation of an incorrect insulin dose. The Director of Nursing confirmed these observations as medication errors, highlighting a significant lapse in the facility's adherence to its medication administration policy.
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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