Menomonee Falls Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Menomonee Falls, Wisconsin.
- Location
- N84 W17049 Menomonee Ave, Menomonee Falls, Wisconsin 53051
- CMS Provider Number
- 525415
- Inspections on file
- 22
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Menomonee Falls Health Services during CMS and state inspections, most recent first.
A resident with multiple diagnoses and a documented intact cognitive status was left with a cup containing six medication pills on the overbed table while sleeping, without a completed self-administration assessment or authorization. An LPN confirmed leaving the medications at the bedside, and the resident later self-administered them after returning from therapy. The DON acknowledged that medications should not be left at the bedside without proper assessment.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care. One resident developed a stage 3 ischium pressure injury, with delayed implementation of treatment orders and inconsistent use of heel boots. Another resident had a DTI inaccurately staged as a Stage I injury, with delayed treatment and inconsistent documentation. The facility failed to adhere to its pressure injury policy, impacting care quality.
A facility failed to notify a resident's HCPOA of new open areas on the resident's foot and ankle, as required by policy. The resident, with severe cognitive impairment, was not properly communicated about their wound status, and documentation in the EMR was incomplete until the survey process began. The DON acknowledged the expectation for immediate notification, but the facility's wound tracker lacked necessary details.
A resident in an LTC facility was not provided care according to their comprehensive care plan and physician orders. The resident, with a history of severe malnutrition and dementia, was observed without prescribed tubigrips and heel boots, essential for preventing pressure injuries. The care plan was not updated with new interventions after identifying an arterial wound, and staff interviews revealed a lack of adherence to the care plan. The DON acknowledged a disconnect in processing treatment orders, leading to a deficiency in care.
A resident with hearing and vision impairments did not receive necessary treatment and assistive devices, as observed during a survey. The resident was frequently seen without glasses or hearing aids, which were documented as needed in their care plan. The facility's staff were either unaware of the requirements or unable to ensure the use of these devices. The resident's hearing aids were reportedly lost, and there was no documentation of efforts to replace them or arrange for an audiology consultation.
Two residents in the facility had incomplete medication administration records over several months, with numerous medications not documented as administered. Despite the facility's policy requiring immediate documentation, staff interviews revealed delays due to a busy environment. The Director of Nursing confirmed the expectation for immediate documentation but did not explain the deficiencies.
Two residents developed stage 3 pressure injuries due to inadequate care and prevention measures. One resident, with multiple health conditions and incontinence, did not receive a comprehensive assessment or updated care plan, leading to a sacral pressure injury. Another resident's coccyx injury was incorrectly staged, delaying treatment. The facility failed to personalize care plans and implement effective pressure injury prevention policies.
A facility failed to provide adequate supervision and assistance devices, resulting in multiple falls and injuries for two residents. One resident experienced several falls due to inadequate investigation and care plan revisions, leading to a hip fracture. Another resident, assessed as requiring supervision while smoking, was found smoking alone, contrary to the facility's policy. The facility's lack of thorough investigations and consistent application of safety interventions highlighted deficiencies in accident prevention and resident supervision.
The facility failed to provide sufficient nursing staff, particularly during night shifts, leading to delayed call light responses and resident concerns. Despite using a scheduling program, the facility was consistently short-staffed, with discrepancies in staffing records. Residents reported long wait times for assistance, especially after medical procedures, and had not been informed of any resolutions to their concerns.
The facility failed to adhere to professional standards for food storage and safety, affecting all 30 residents. A surveyor observed a jug of barbeque sauce on the floor, an unlabeled bag of white powder, and undated food items in the kitchen. The dietary manager admitted the sauce was used to prop open a door, violating policy. The nursing home administrator was informed, but no further details were provided.
The facility failed to properly dispose of garbage and refuse in the outside storage area, leading to an accumulation of debris, including wood pallets, a refrigerator, and garbage bags mixed with pine needles and pinecones. The Dietary Manager and Maintenance Director were unclear about their responsibilities, resulting in inadequate maintenance of the area.
The facility failed to maintain consistent staffing on weekends, as revealed by the PBJ data for the first quarter of fiscal year 2023, which showed excessively low weekend staffing. The facility's assessment required specific staffing levels based on resident census and acuity, but discrepancies were found, particularly on weekends. The DON used Smart Linx for scheduling, but the facility was still flagged for low staffing. The Regional VP identified a systemic issue with agency staff hours not being accurately reported, affecting weekend staffing data.
The facility failed to maintain an effective infection control program, with missing data in infection logs, unreviewed policies, and inadequate water management practices. A resident with C-Diff was not logged, and staff did not follow proper hygiene protocols, such as handwashing and medication handling. Additionally, the water management plan lacked documentation and involvement from the DON, leading to potential risks of Legionella spread.
The facility failed to provide a safe, clean, and comfortable homelike environment, affecting residents in the dining room and two residents observed for care. Meals were served on trays, and strong urine odors and yellow stains were noted in residents' rooms.
The facility failed to document code status for several residents, with missing or unsigned DNR forms and lack of evidence of discussions confirming residents' wishes. The process relied on verbal confirmation and electronic entries without formal documentation.
The facility failed to address pharmacy recommendations for several residents, leading to deficiencies in medication management. Recommendations for dosage specifications, medication discontinuation, and assessments were repeatedly ignored, affecting residents with conditions such as rheumatoid arthritis, anxiety, and epilepsy. The lack of follow-up on these recommendations highlights systemic issues in the facility's medication management processes.
A resident was not provided with the necessary Advanced Beneficiary Notice (ABN) or Notice of Medicare Non-Coverage (NOMNC) when their Medicare Part A benefits ended. The facility's regional vice president confirmed the absence of these documents, and the social services coordinator, new to the role, was unable to locate them. The nursing home administrator was informed of the issue.
The facility failed to provide required written transfer notices to residents and their representatives during hospitalizations, lacking details such as appeal rights and ombudsman contact information. Staff interviews revealed confusion about the responsibility for issuing these notices, and the provided forms were missing necessary regulatory information.
The facility failed to notify residents and their representatives of the bed-hold policy during hospital transfers, affecting three residents who were hospitalized. Despite the facility's policy requiring notification within 24 hours of transfer, no such notices were provided. Interviews with staff revealed confusion about responsibility for this task, and documentation was lacking for all affected residents.
A resident diagnosed with a psychotic disorder did not have an updated PASARR level 1 screen or a level 2 referral, despite the new mental health diagnosis. The facility's records lacked evidence of the necessary updates, and the social service staff confirmed that while a new level 1 screen was completed, a level 2 screen had not yet been done.
A resident with multiple medical conditions, including bilateral amputation and chronic heart failure, did not receive scheduled showers at a facility. Despite being scheduled for showers twice weekly, documentation and interviews revealed inconsistencies and a lack of clear policy, resulting in the resident not receiving necessary grooming services.
The facility failed to provide adequate wound care and treatment documentation for three residents. A resident with lymphedema and diuretic use lacked a comprehensive care plan and monitoring for adverse reactions. Another resident with a neoplasm was not properly assessed, and staff did not verify or assist with treatment. A third resident with a venous stasis ulcer did not receive treatments as ordered, and the wound was not properly cleaned or documented. These deficiencies highlight a lack of adherence to professional standards of practice in wound care.
A resident readmitted with a Foley catheter was not assessed for removal, and the facility failed to follow up on a urology referral. The resident's care plan lacked documentation of the catheter, and there was inconsistent recording of urinary continence status. The facility's policy did not address catheter removal assessment.
Two residents experienced significant weight changes without proper monitoring or intervention. One resident lost 48 pounds over three months, with no re-weighs or notifications to the dietician or physician. Another resident had a physician's order for weekly weights, but several weeks' weights were not documented. The facility failed to adhere to its weight monitoring policy, leading to deficiencies in nutritional care.
A facility failed to conduct a trauma-informed care assessment for a resident with PTSD, anxiety, and depression, resulting in a non-individualized care plan. The resident confirmed that no one had asked about her PTSD triggers, and the social worker was unaware of the requirement for trauma assessments. The CNA Kardex lacked specific interventions for the resident's PTSD, leading to a deficiency noted by the surveyor.
The facility failed to monitor heart rates for two residents before administering Metoprolol, as required by physician orders, and administered an unnecessary antibiotic to another resident without adequate signs of a UTI. The antibiotic was continued at the request of a family member, despite the resident not meeting infection criteria.
A facility was found to have a medication error rate of 21.05%, significantly above the acceptable threshold. Errors included improper crushing of extended-release medication, holding medication without physician orders, and failure to administer multiple prescribed medications to residents. The facility's documentation did not show that physicians were notified of these omissions, indicating non-compliance with medication administration policies.
The facility failed to properly label insulin pens, as observed in the Deerpath medication cart. Several insulin pens were found open and used without being dated when opened, and one pen lacked a proper resident label. These issues were noted by a surveyor and reported to the RN and DON, but no further information was provided.
A Life Enrichment Specialist, not certified as a CNA, was observed feeding a resident with multiple diagnoses, including chronic kidney disease and diabetes, without completing a state-approved training course. The facility's DON confirmed the absence of paid feeding assistants and the LES's lack of certification. Despite a detailed care plan requiring assistance with eating, the LES fed the resident breakfast on two occasions, leading to a deficiency finding.
The facility did not have a hospice policy and procedure, affecting the coordination of care for residents receiving hospice services. This deficiency was identified when surveyors found no hospice contract or policy in the facility's records, and the DON confirmed its absence. Two residents receiving hospice care were impacted, with one having severe malnutrition and the other with chronic kidney disease and other conditions. The facility's hospice care plans lacked specificity, and there was no designated IDT member for coordinating care with hospice services.
The facility failed to document influenza and pneumococcal immunizations for three residents, as required by their policies. Medical records lacked documentation of whether the residents received or refused these vaccines, which was only confirmed through the Wisconsin Immunization Registry after surveyor inquiry. The Director of Nursing oversees the immunization program, but the process was not effectively documented, leading to the deficiency.
Two residents were found self-administering medications without proper assessments or physician orders. One resident, with multiple health conditions, had medications on her over-bed table without a self-medication assessment. Another resident, with a history of cancer and other diagnoses, was performing his own wound treatment without oversight, while nursing staff inaccurately documented treatment administration. The facility failed to follow its policy requiring assessments and orders for self-administration.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a resident was not assessed for clinical appropriateness to self-administer medications, yet was left with a cup containing six medication pills on the overbed table while sleeping. The resident's medical record did not include a completed self-administration assessment, and the quarterly MDS indicated the resident was cognitively intact. Despite this, the facility's policy requires specific authorization and assessment before allowing self-administration of medications. The LPN confirmed leaving the medications at the bedside while the resident was asleep, and the resident later confirmed self-administering the medications after returning from therapy, expressing surprise at finding the medications left out. Observations showed the medication cup remained on the overbed table for several hours, even when the resident was not present in the room. The MAR indicated the medications were documented as administered at the scheduled time, although the resident did not take them until much later. The DON confirmed that medications should not be left at the bedside without proper assessment and authorization. No explanation was provided for the failure to ensure the resident was clinically appropriate for self-administration of medications.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for two residents, R5 and R7, leading to deficiencies in pressure ulcer care. R5, who was at risk for pressure injuries, developed a stage 3 ischium pressure injury. Despite recommendations from the wound doctor to upgrade the offloading chair cushion and initiate specific treatment orders, these were not implemented until several days later. Observations revealed that R5 was not repositioned every two hours as required, and heel boots were not consistently worn, contrary to the care plan. R7 was admitted with a Deep Tissue Injury (DTI) to the left heel, which was inaccurately staged as a Stage I pressure injury by RN-D. The treatment for the left heel was delayed by two days post-admission, and there was a lack of documented assessments after a certain date, despite the presence of a dark area on the heel. The facility's documentation was inconsistent, with conflicting reports about the staging and healing status of the pressure injury. The facility's policy on pressure injuries was not adhered to, as evidenced by the lack of timely updates to care plans and the failure to implement recommended interventions. The Director of Nursing acknowledged the oversight in processing treatment orders and the absence of a root cause analysis for the development of new pressure injuries. These deficiencies highlight a breakdown in communication and documentation processes within the facility, impacting the quality of care provided to residents.
Failure to Notify HCPOA of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the health care power of attorney (HCPOA) for a resident when there was a change in condition and a need to alter treatment. Specifically, the HCPOA was not informed when the resident developed open areas below the left pinky toe and on the left outer ankle on November 5, 2024. The facility's policy requires informing residents or their responsible parties about the presence and status of wounds, but this was not adhered to in this case. The Director of Nursing (DON) acknowledged that there was no specific facility policy for notification, and the expectation was that the representative should be notified immediately. The resident in question had a history of severe cognitive impairment, requiring total assistance with activities of daily living, and was dependent on staff for mobility and personal care. The resident's HCPOA was only informed of the wound status by the wound doctor, not by the facility staff. The facility's wound tracker documentation was incomplete, with missing information on who was notified and when. The surveyor's review of the electronic medical record (EMR) confirmed that the notification section was blank until the survey process began, indicating a lapse in communication and documentation by the facility staff.
Failure to Adhere to Resident's Care Plan and Physician Orders
Penalty
Summary
The facility staff failed to provide care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident, identified as R5. R5 was observed not wearing the prescribed size D double tubigrips on their bilateral lower extremities, which were ordered to be worn 23 hours a day as tolerated. Additionally, R5 was not wearing the physician-ordered off-loading bilateral heel boots during the survey process. These observations were made despite the resident's care plan and physician orders clearly documenting the necessity of these interventions to prevent pressure injuries and promote healing. R5, who has a history of severe protein-calorie malnutrition, dementia, and other comorbidities, was admitted to the facility with existing pressure injuries and was at risk for developing further pressure injuries. The resident's care plan was not updated with new interventions following the identification of an arterial open area on R5's right first toe. The care plan was only revised on the first day of the survey process, and no new interventions were implemented at the time of identification. Furthermore, the facility's Director of Nursing acknowledged that the treatment orders from a wound doctor were not processed in a timely manner, contributing to the lack of appropriate care. Throughout the survey process, R5 was observed multiple times without the necessary tubigrips and heel boots, and there was no evidence of repositioning every two hours as required. Interviews with facility staff, including a CNA and an LPN, revealed a lack of awareness and adherence to the resident's care plan. The Director of Nursing admitted to a disconnect in processing treatment orders and acknowledged that the care plan should have been updated with new interventions when the open areas were first identified. This failure to ensure that R5 received the necessary treatment and services consistent with professional standards of practice resulted in a deficiency in the care provided to the resident.
Failure to Provide Necessary Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that a resident with hearing and vision impairments received the necessary treatment and assistive devices. The resident, who has diagnoses including dementia, sensorineural hearing loss, and severe protein-calorie malnutrition, was observed multiple times without wearing glasses or hearing aids. The resident's care plan and Kardex indicated the need for these devices, yet they were not consistently used or available. The resident's hearing aids were reportedly lost, and there was no documentation of efforts to replace them or arrange for an audiology consultation. The facility's policy on the use of assistive devices requires that such devices be provided based on a comprehensive assessment and in accordance with the resident's care plan. However, the staff, including a CNA and an LPN, were either unaware of the resident's need for hearing aids or unable to ensure their use. The Director of Nursing acknowledged the loss of the hearing aids and the need for a care plan update but did not provide evidence of actions taken to address the issue. The resident's medical records showed a lack of follow-up on a physician's order for an audiology consultation, which had not been completed since March 2024. Observations during the survey revealed that the resident's glasses were often not within reach, and the resident was not wearing them during meals or while watching television. The facility did not provide additional information to explain why the necessary treatment and services were not provided to promote the resident's quality of life.
Incomplete Medication Administration Records for Two Residents
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) were complete and accurate for two residents, R1 and R3, over a period from September 2024 to November 2024. The MARs for both residents contained numerous empty signature boxes, indicating that medications were not documented as administered by the nursing professionals responsible for their care. This lack of documentation was in direct violation of the facility's policy, which mandates that the individual administering the medication must record the administration immediately after the medication is given. R1, who was admitted with multiple diagnoses including Alzheimer's disease, diabetes, and epilepsy, had several medications not documented as administered across the three months. These medications included critical treatments for hypertension, diabetes, anxiety, and seizures, among others. Additionally, blood sugar readings were not documented on several occasions, which is particularly concerning given R1's diabetic condition. Despite the facility's policy requiring immediate documentation, these omissions persisted, raising concerns about the accuracy and reliability of R1's medication management. Similarly, R3, who was cognitively intact and had a range of health issues including diabetes, chronic obstructive pulmonary disease, and anxiety, also had numerous medications not documented as administered. These included medications for heart failure, anxiety, and diabetes, as well as blood sugar readings. Interviews with staff revealed that documentation was sometimes delayed due to the facility's busy environment, with nurses noting that they would document when time allowed. The Director of Nursing acknowledged the expectation for immediate documentation but did not provide additional information on why these deficiencies occurred, despite daily audits being conducted.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, resulting in the development of stage 3 pressure injuries. Resident R5, who was admitted with multiple health conditions including diabetes, chronic kidney disease, and incontinence, developed a stage 3 pressure injury on the sacrum. The facility did not conduct a comprehensive assessment or update the care plan to address R5's high risk for pressure injuries, despite the resident's dependency on staff for mobility and incontinence care. The care plan lacked specific instructions for repositioning frequency and did not account for R5's frequent loose stools due to C-diff, which increased the risk of skin breakdown. Resident R26, with diagnoses including chronic kidney disease and diabetes, also developed a stage 3 pressure injury on the coccyx. The initial assessment of the injury was incomplete and incorrectly staged as a stage 2, delaying appropriate treatment. The care plan was not revised promptly to reflect the new pressure injury, and there was a lack of comprehensive assessment to determine the need for increased repositioning and skin care interventions. The facility's failure to accurately assess and document the pressure injury contributed to inadequate care and delayed treatment. Both residents' care plans were not personalized to their specific needs, and there was a lack of timely updates and comprehensive assessments. The facility's policies on pressure injury prevention and care were not effectively implemented, leading to the development and progression of pressure injuries in these residents. The surveyor noted discrepancies in documentation and care plan revisions, highlighting systemic issues in the facility's approach to pressure ulcer management.
Inadequate Supervision and Care Plan Revisions Lead to Resident Falls and Smoking Risks
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, leading to multiple falls and injuries. One resident, with a history of falls and cognitive impairments, experienced several falls that were not thoroughly investigated, and the root causes were not determined. The care plan was not consistently revised to address the risks, and interventions were not always implemented, such as the use of a gait belt during transfers. This resident suffered a hip fracture and other injuries due to inadequate supervision and failure to follow the care plan. Another resident, who was assessed as requiring supervision while smoking, was found to be smoking alone without the necessary oversight. The facility's policy required that smoking materials be controlled by staff, but the resident reported having access to their own smoking materials and smoking unsupervised. This lack of supervision was contrary to the resident's care plan and the facility's smoking policy, which aimed to prevent smoking-related injuries. The facility's failure to conduct thorough investigations and revise care plans appropriately contributed to the ongoing safety risks for these residents. The lack of staff interviews and documentation of root causes for the falls, as well as the inconsistent application of safety interventions, highlighted deficiencies in the facility's approach to accident prevention and resident supervision.
Inadequate Staffing Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as observed during a survey. The Director of Nursing (DON) explained that staffing levels are determined based on the number of residents and their acuity needs, using a scheduling program called Smart Linx. However, the surveyor found that the facility was consistently short-staffed, particularly during the night (NOC) shifts, with missing Certified Nursing Assistants (CNAs) and nurses on several occasions. This staffing shortage was documented over multiple dates, both in the current year and the previous fiscal quarter, indicating a pattern of inadequate staffing. Residents expressed concerns about the insufficient staffing levels, which led to delayed responses to call lights. During a Resident Council meeting, residents reported long wait times for assistance, especially after medical procedures or surgeries. They noted that these delays were concerning, particularly if they experienced medical changes requiring more frequent assistance. One resident described the call light wait times as "horrible," and another resident confirmed witnessing prolonged call light activations for their neighbor. The surveyor noted discrepancies between the facility's daily schedules and actual timecard punches, suggesting inaccuracies in staffing records. Despite residents raising these concerns with the facility previously, they had not been informed of any resolutions or progress. The surveyor communicated these findings to the DON, but no further information was provided to explain why the facility failed to ensure adequate staffing to maintain the residents' well-being.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and served in accordance with professional standards for food service safety, potentially affecting all 30 residents. During an initial tour of the kitchen area, a surveyor observed several violations of food storage protocols. A jug of barbeque sauce was found sitting on the floor of the dry storage area, contrary to the facility's policy that requires all items to be stored on shelves at least six inches above the floor. Additionally, an open bag containing an unlabeled white powder was found on a shelf, and a bag of cheese omelets in the freezer was open and undated. In the lunch prep refrigerator, a container of hot dogs sitting in liquid and a pitcher with brown liquid were both found without labels or dates. The dietary manager was interviewed and acknowledged the observations, explaining that the barbeque sauce was used to prop open a door, which is against the facility's policy. The dietary manager stated that staff had been educated on the importance of not propping doors open with food products. The nursing home administrator was also informed of these observations, but no further information was provided at the time. These findings indicate a lack of adherence to the facility's food storage policies, which are based on the FDA Food Code, and highlight the need for improved compliance with food safety standards.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the outside garbage storage receptacles, as observed by a surveyor. The facility's policy, dated August 2017, requires that all garbage and refuse be collected and disposed of safely and efficiently. However, during an inspection, the surveyor observed a significant accumulation of debris, including 20 wood pallets, a refrigerator, and various garbage bags mixed with pine needles and pinecones, behind the dumpsters. The Dietary Manager was unsure about which staff was responsible for maintaining the cleanliness of the dumpster area, indicating a lack of clear responsibility and oversight. The Maintenance Director, upon being shown the area, expressed uncertainty about how to dispose of the refrigerator and pallets and acknowledged the need to regularly clean the area of pinecones and needles. Despite checking the area daily, the Maintenance Director had not addressed the accumulation of debris. The Nursing Home Administrator was informed of the situation and acknowledged the need to assist in resolving the issue, but at the time of the survey, no immediate corrective actions had been implemented to address the deficiency.
Inconsistent Weekend Staffing in Facility
Penalty
Summary
The facility did not ensure consistent staffing on weekends to meet the needs of the 30 residents residing in the facility. During the review of the payroll-based journal (PBJ) staffing data for the first quarter of the federal fiscal year 2023, the facility was flagged for excessively low weekend staffing. The facility's assessment indicated that the average daily census was between 28 to 32 residents, requiring 5 licensed nurses and 8 certified nursing assistants (CNAs) to provide direct care. The staffing requirements included having one registered nurse (RN) or licensed practical nurse (LPN) per shift, with specific ratios for day, PM, and night shifts. However, the facility's PBJ data revealed a discrepancy in staffing levels, particularly on weekends. The Director of Nursing (DON) stated that the facility's staffing needs are determined by the census and acuity of residents, using a scheduling program called Smart Linx. Despite the program's algorithm creating an ideal schedule, the facility was still triggered for low weekend staffing. The Regional Vice President (VP) acknowledged that the facility was automatically down 16 hours on weekends due to the absence of certain staff roles, such as the Minimum Data Set (MDS) nurse and Social Services. Additionally, a systemic issue was identified where agency staff hours were not being accurately pulled into the PBJ reporting, affecting the reported weekend staffing hours. This issue was attributed to a checkbox in Smart Linx not being checked, which led to agency hours not being integrated into the system, impacting the facility's staffing data.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which was evident from several deficiencies observed during the survey. The infection control logs for multiple months lacked critical information such as the date of onset, organism, and isolation type, and did not include resolved dates for infections. Baseline rates of infections were not calculated for several months, and a resident with C-Diff was not included in the infection log for February 2024. Additionally, infection control policies and procedures were not reviewed annually, and the Director of Nursing, who was supposed to be part of the water management team, was not involved in the program. The facility's water management program was inadequate, lacking specific flow charts and documentation of areas where water was flushed to prevent the spread of Legionella. The Maintenance Director was unable to provide a map or diagram showing dead ends in the water system and did not have records of when and where water was flushed. The water management plan was not included in the facility's assessment, and there was no documentation of flushing water in empty resident rooms, which could lead to stagnant water. Several infection control practices were not followed by staff, including a registered nurse touching medication with bare hands and a certified nursing assistant not washing hands between assisting residents to eat. A resident's urinary collection bag was observed lying directly on the floor, which is against the facility's catheter care policy. These actions and inactions contributed to the facility's failure to maintain a safe and sanitary environment for residents.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility did not provide a safe, clean, comfortable homelike environment, which had the potential to affect all residents eating in the dining room and two residents observed for care. Surveyors observed dining room staff serving meals on trays directly to residents in the dining room on multiple occasions. The Director of Nursing (DON) acknowledged the issue and stated it would be addressed with staff, but no further information was provided at the time of the surveyor's observation. Additionally, one resident's room had a strong urine odor and yellow stains on the bed sheet on multiple occasions. Despite the resident stating they did not need assistance with toileting, the surveyor noted the persistent odor and stains. Another resident was observed being repositioned by CNAs, who discovered a yellow stain and urine odor on the bedding. The CNAs took steps to address the issue, but the surveyor noted the deficiency in maintaining a clean and comfortable environment for the residents.
Deficiency in Code Status Documentation
Penalty
Summary
The facility failed to provide proper code status documentation for five residents, leading to a deficiency in adhering to residents' rights to formulate advance directives. For Resident 23, there was no documented code status upon admission, and the code status was only entered after the surveyor's inquiry. The Director of Nursing (DON) and Social Services staff were unable to provide evidence of prior documentation or communication regarding the resident's code status wishes. Resident 21 had a documented DNR status on the electronic record, but the state DNR form was not signed by the physician, leaving the resident's code status incomplete. The surveyor noted that the facility's process for confirming code status was inconsistent, with responsibilities shared between nursing staff and social services, but lacking a clear protocol for ensuring physician signatures on DNR forms. For Residents 5 and 10, the facility's records indicated a full code status, but there was no signed documentation or evidence of discussions with the residents to confirm their wishes. The facility relied on verbal confirmation and entries into the electronic system without a formalized process for obtaining written consent or documentation of the residents' code status preferences.
Failure to Address Pharmacy Recommendations in Medication Regimen Review
Penalty
Summary
The facility failed to ensure that recommendations made through the medication regimen review (MRR) were addressed for several residents, leading to deficiencies in medication management. For Resident 19, pharmacy recommendations to specify the dosage in grams for Diclofenac Sodium External Gel were repeatedly ignored over several months. Despite the recommendations being documented in November, December, and February, no follow-up actions were taken by the nursing staff, and the issue persisted until it was brought to the attention of the Director of Nursing (DON). Resident 2 also experienced a lack of follow-up on pharmacy recommendations. The pharmacist repeatedly recommended discontinuing Amitriptyline and conducting an AIMS assessment, but these recommendations were not addressed by the physician. The AIMS assessment was delayed until April, despite being recommended in December and February. Similarly, Resident 7's pharmacy recommendations regarding pain management were not addressed, with the physician failing to evaluate the use of Oxycodone and Tramadol as suggested by the pharmacist. Other residents, such as Resident 4 and Resident 26, also faced similar issues. Resident 4's pharmacy recommendations to reduce Ferrous Sulfate and conduct an AIMS assessment were not followed up on, and Resident 26's physician did not address recommendations to monitor therapy with specific tests. These repeated failures to act on pharmacy recommendations highlight a systemic issue within the facility's medication management processes.
Failure to Provide Required Medicare Coverage Notifications
Penalty
Summary
The facility failed to provide a resident with the necessary written beneficiary protection notifications when their Medicare Part A benefits ended. Specifically, the resident, identified as R7, did not receive an Advanced Beneficiary Notice (ABN), which should have included information about financial liability and appeal rights. The Notice of Medicare Non-Coverage (NOMNC) was also not provided, which is required to inform the resident or their representative that Medicare Part A coverage is ending, along with details on appeal rights and contact information for a third-party reviewer. During the survey, the regional vice president of success (VPS)-E confirmed that there was no ABN on file for the resident, despite the Medicare Part A Skilled Services episode having started on November 13, 2023, and ended on January 13, 2023. The social services coordinator (SSC)-I, who was new to the position, was unable to locate the necessary paperwork and acknowledged that it appeared the resident was never given the required forms to review or sign. The nursing home administrator (NHA)-A and VPS-E were informed of these concerns, but no additional information was provided at that time.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, including the necessary details such as the reason for transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This deficiency was identified for three residents who were hospitalized without receiving the required written transfer notices. The facility's policy on emergency transfers and discharges mandates that transfer notices be provided as soon as practicable, but this was not adhered to in the cases reviewed. For one resident, the medical records indicated hospitalization due to a mild heart attack, but there was no evidence of a written transfer notice being provided to the resident or their representative. Interviews with facility staff revealed a lack of clarity regarding who was responsible for issuing these notices. The Director of Nursing admitted to recently learning about the requirement to notify the ombudsman, which had not been done until late April. Another resident was transferred to the hospital following a fall, yet again, no written transfer notice was found in the medical records. The staff involved in the transfer process were unsure about the procedure for providing written notices. A third resident, who had multiple hospitalizations, also did not receive the required transfer notices. The facility's provided transfer forms lacked the necessary regulatory information, including appeal rights and ombudsman contact details, indicating a systemic issue in the facility's transfer notification process.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified for three residents (R7, R21, and R5) who were hospitalized. The facility's policy mandates that a notice of the bed-hold policy be provided to the resident and their representative at the time of transfer, or no later than 24 hours after the transfer. However, in these cases, no such notices were provided. Resident R7 was hospitalized following a mild heart attack and was admitted to the ICU. Despite the transfer and subsequent readmission to the facility, there was no documentation of the bed-hold policy being communicated to R7 or their representative. Interviews with facility staff revealed a lack of clarity regarding who was responsible for providing this information, with the LPN indicating it was the role of the Social Worker or Admission Coordinator, and the DON admitting unfamiliarity with the requirement. Similarly, Resident R21 was transferred to the hospital after a fall and admitted to the orthopedic floor. Again, there was no evidence of the bed-hold policy being communicated. Resident R5, who had multiple hospitalizations, also did not receive the required bed-hold information. Interviews with Social Services and the Regional VP confirmed the absence of documentation for R5, highlighting a systemic issue in the facility's process for handling bed-hold notifications.
Failure to Update PASARR for Resident with New Psychotic Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident, identified as R21, had an updated Preadmission Screening and Resident Review (PASARR) following a new diagnosis of a psychotic disorder with delusions. Initially admitted with various medical conditions, R21's level 1 PASARR dated June 23, 2022, indicated no mental illness, and thus, a level 2 screen was not required at that time. However, after being diagnosed with a psychotic disorder on June 26, 2023, the facility did not update the level 1 screen or initiate a level 2 referral, which is necessary for residents with mental health diagnoses. The surveyor's review of R21's medical records on April 28, 2024, revealed the absence of an updated level 1 screen or a level 2 PASARR. Despite the social service staff's belief that the paperwork had been completed and submitted to the prior nursing home administrator, there was no evidence of this in the records. The social service staff confirmed that a new level 1 screen was completed on April 30, 2024, but a level 2 screen had not yet been done. This oversight was communicated to the current nursing home administrator, director of nursing, and regional vice president.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R10, received necessary services to maintain good grooming, specifically in the area of showering. R10, who has multiple medical conditions including bilateral amputation, Type 2 Diabetes Mellitus, and chronic Congestive Heart Failure, was admitted to the facility and expressed that it was very important to choose between different types of bathing. Despite this, R10 reported not receiving a shower since admission and stated that staff did not offer one, although they assisted with washing up and dressing. The facility's policy requires that residents unable to perform activities of daily living receive necessary services, but documentation showed inconsistencies in providing showers to R10. The facility's records, including the Point of Care documentation and shower assignment logs, indicated that R10 was scheduled for showers twice a week, but there was a lack of evidence that these showers were provided. The surveyor's review of documentation from February to April revealed that R10's name appeared on the shower assignment sheets only twice, with one instance marked as a refusal. Interviews with staff, including a Registered Nurse and the VP of Clinical Services, revealed that there was no clear policy on shower frequency, and the facility relied on aides to document shower completion or refusal. The surveyor noted the absence of documentation for showers on several occasions, leading to the deficiency finding.
Deficiencies in Wound Care and Treatment Documentation
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds. For Resident 19, there was no comprehensive care plan in place for diuretic use or lymphedema treatments, and monitoring for adverse reactions was not conducted. The care plan and care Kardex were not updated to reflect the current treatment, and no orders for treatment or interventions could be located. Additionally, the resident was observed with leg wraps for lymphedema, but there were no orders or care plans addressing the use of these wraps or monitoring for adverse effects. Resident 25, who has a neoplasm on the perineal area, was not being properly assessed by nursing staff. The resident self-applied ointment for the condition, but staff did not verify or assist with the treatment, nor did they document any assessments of the wound. The facility's records showed inconsistencies in the documentation of wound assessments and treatments, with missing measurements and descriptions of the neoplasm's condition over time. Resident 26, with a venous stasis ulcer, did not receive treatments according to orders. The ulcer was not comprehensively assessed, and observations revealed that the wound was not cleaned during treatment. The treatment administration record was inaccurately initialed as completed, despite evidence to the contrary. Additionally, the wound physician was not informed of the ulcer, and the wound was not properly cleansed before dressing application, indicating a lack of adherence to proper wound care protocols.
Failure to Assess and Follow Up on Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident who was readmitted with an indwelling Foley catheter was assessed for its removal as soon as possible. The resident, who had multiple diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Hydronephrosis with renal and ureteral calculous obstruction, was discharged from the hospital with a Foley catheter for retention and a urology referral. However, the facility did not follow up with urology or assess the resident for catheter removal. The resident's medical records did not include a care plan for the Foley catheter, and there was inconsistent documentation regarding the resident's urinary continence status. The facility's Director of Nursing (DON) and staff failed to ensure that the resident's care plan and Kardex in Point Click Care (PCC) reflected the presence of the Foley catheter. Additionally, there was no evidence of an appointment being scheduled for the urology referral, and the facility's appointment book did not list any appointments for the resident. The facility's policy on catheter care did not include specific guidelines for assessing the need for catheter removal. The deficiency was identified during a survey when the surveyor noted the lack of follow-up and documentation regarding the resident's catheter care.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, as evidenced by the severe weight loss experienced by two residents, R5 and R21. R5, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus and Chronic Kidney Disease, experienced a significant weight loss of 48 pounds over three months. Despite the drastic changes in weight, neither the dietician nor the physician was notified, and no new interventions were implemented. The facility did not question the accuracy of the weights recorded, and re-weighs were not completed as per facility policy. R5's weight records showed inconsistencies, with a sudden drop from 185 pounds to 144.4 pounds within five days, and further to 100.4 pounds in another five days. These discrepancies were not addressed, and the dietician was not informed of these significant changes. The dietician, upon reviewing the records, noted the inconsistencies but was not notified in a timely manner to take corrective action. The lack of communication and failure to adhere to the weight monitoring policy contributed to the oversight in R5's care. Similarly, R21, who had a physician's order for weekly weights due to a history of weight loss, did not have weights recorded for several weeks. Although the medication administration record indicated that weights were taken, they were not documented in the medical record. This lack of documentation and monitoring led to a failure in following the physician's orders, further highlighting the facility's deficiency in maintaining proper nutritional monitoring and intervention for its residents.
Failure to Conduct Trauma-Informed Care Assessment
Penalty
Summary
The facility failed to comprehensively assess a resident for trauma-informed care and develop a personalized care plan to mitigate triggers and prevent re-traumatization. The facility's Trauma Informed Care Policy outlines the need for a multi-pronged approach to identify a resident's history of trauma and to document triggers that may cause re-traumatization. However, the surveyor found that the facility did not conduct a trauma-informed care assessment for a resident diagnosed with PTSD, anxiety disorder, and depressive disorder. The resident's care plan, initiated on November 7, 2023, included general interventions such as determining triggers, de-escalation preferences, and providing a safe environment. Despite these interventions, the CNA Kardex did not address the resident's PTSD or specific triggers. During an interview, the resident confirmed that no one at the facility had asked about her PTSD triggers, and she had not discussed her PTSD with the social worker, who was new to the facility. The surveyor's investigation revealed that the social service staff had not conducted trauma assessments, and the social worker was unsure if it was a requirement. The social worker later acknowledged the need to address the resident's PTSD diagnosis and care plan. The facility's failure to individualize the care plan and conduct a trauma-informed assessment led to the deficiency noted by the surveyor.
Failure to Monitor Vital Signs and Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary drugs, as required by regulations. For one resident with hypertension, the facility did not monitor the heart rate as per physician orders before administering Metoprolol Succinate ER, which was supposed to be held if the heart rate was less than 60. The resident's heart rate was not recorded in the medication administration record for March and April 2024, and the last recorded pulse was on April 11, 2024. Similarly, another resident with chronic diastolic heart failure and atrial fibrillation was not monitored for heart rate before receiving Metoprolol, despite physician orders to hold the medication if the heart rate was below 60. The last documented pulse for this resident was on February 29, 2024. Additionally, the facility administered Keflex, an antibiotic, to a resident without adequate signs or symptoms of a urinary tract infection (UTI). The resident returned from the hospital with a UTI diagnosis and an order for Keflex, but there was no documentation of urinary signs and symptoms prior to the hospital transfer. The Director of Nursing acknowledged that the resident did not meet the criteria for infection and that the antibiotic was continued at the request of the resident's granddaughter, despite the power of attorney not being activated. The hospital did not perform a culture and sensitivity test to confirm the need for the antibiotic.
High Medication Error Rate and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 21.05%. This deficiency was identified through observations, interviews, and record reviews conducted by surveyors. Several instances of medication errors were noted, including the improper crushing of Metoprolol Succinate ER for a resident, which is against the facility's policy for extended-release medications. Additionally, a resident's Amlodipine Besylate was held without any physician-ordered parameters to justify the action. Further observations revealed that another resident did not receive multiple prescribed medications, including Farxiga, Isosorbide Mononitrate ER, Metoprolol Succinate ER, Prozac, and Spiriva inhaler, as ordered. The facility's documentation did not provide evidence that the physician was notified of these omissions, which spanned several days. Similarly, another resident did not receive Bumetanide as ordered, despite the medication being signed out as administered in the Medication Administration Record (MAR). The facility's policy on medication administration requires that medications be administered as prescribed and that any deviations, such as withholding or refusing medication, be documented with an explanatory note. However, the surveyor's findings indicated a lack of adherence to these protocols, contributing to the high medication error rate. The Director of Nursing was informed of these observations, but no additional information was provided to address the issues identified.
Improper Labeling of Insulin Pens
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding insulin pens. During an observation of the Deerpath medication cart, several insulin pens were found to be improperly labeled. An Insulin Aspart pen belonging to a resident was open and used but not dated when opened. A Levemir insulin flex pen lacked a label with a resident's name, although a torn white label with a name and date was noted. Another Aspart insulin pen and a Lantus insulin pen, both belonging to the same resident, were also open and used without being dated when opened. These deficiencies were brought to the attention of a Registered Nurse and the Director of Nursing, but no additional information was provided.
Uncertified Staff Feeding Resident
Penalty
Summary
The facility failed to ensure that a staff member, who was not a Certified Nursing Assistant (CNA), had completed a state-approved training course before feeding a resident. The Life Enrichment Specialist (LES) was observed feeding a resident, identified as R26, on two consecutive days without the necessary certification. The Director of Nursing confirmed that the facility did not have any paid feeding assistants and that the LES was not a CNA. The LES had previously worked as a hospitality aide at a sister facility and was not listed on the Wisconsin registry for CNAs. The resident, R26, had multiple diagnoses, including chronic kidney disease stage 5, diabetes mellitus, encephalopathy, and epilepsy. The care plan for R26 included various interventions related to nutritional and hydration status, as well as feeding strategies due to difficulty communicating. Despite these detailed care plans, the LES, who was not certified, was observed feeding R26 breakfast on two occasions. The resident's care plan required assistance with eating, and the LES was seen feeding the resident scrambled eggs without the appropriate certification. The surveyor's observations and interviews revealed that the LES had been working at the facility for about a month and was not aware of her CNA certification status. The facility's Regional Vice President and Director of Nursing were informed of the situation, and it was noted that the LES was relieved by a certified employee. The nurse's note documented that the resident did not experience any issues with swallowing during the feeding by the non-certified employee, but the incident highlighted a deficiency in ensuring that staff feeding residents are appropriately trained and certified.
Lack of Hospice Policy and Procedure in Facility
Penalty
Summary
The facility failed to ensure the presence of a hospice policy and procedure, which is crucial for designating a member of the Interdisciplinary Team (IDT) responsible for communicating with hospice services for the coordination of care. This deficiency was identified during a survey when the facility was unable to provide a hospice policy and procedure, affecting four residents receiving hospice services. Specifically, the surveyors noted that the facility did not have a hospice contract in their survey binder, and the Director of Nursing (DON) confirmed the absence of such a policy. This lack of policy meant there was no clear indication of who the representatives were between the facility and hospice for coordinating care, leaving staff without guidance on whom to contact. The deficiency was further highlighted in the cases of two residents, one of whom was admitted with severe protein calorie malnutrition and enrolled in hospice care. The other resident had multiple diagnoses, including chronic kidney disease and diabetes, and was receiving hospice care after refusing dialysis. The facility's hospice care plan for this resident included interventions such as medication administration and hospice staff visits but lacked specificity regarding the type of care required. The absence of a hospice policy meant there was no coordinated plan of care or clarity on the responsibilities of the facility and hospice staff, as confirmed by the DON during the survey.
Deficiency in Immunization Documentation for Residents
Penalty
Summary
The facility failed to ensure that three residents were offered and documented for influenza and pneumococcal immunizations, as required by their policies. The medical records for these residents did not contain any documentation indicating whether they received or refused these vaccines. This lack of documentation was identified during a survey, which revealed that the facility did not have the necessary immunization information until it was requested by the surveyor. Resident 5's medical record lacked documentation of influenza and pneumococcal vaccinations, although the Wisconsin Immunization Registry (WIR) later confirmed that the resident had received these vaccines. Similarly, Resident 332's medical record did not show any information about these vaccines, but the WIR indicated that the resident had received them. Resident 26's record showed an influenza vaccination but lacked documentation for the pneumococcal vaccine, which was later confirmed through the WIR. The Director of Nursing, who oversees the immunization program, explained that the facility's process involves reviewing vaccination history and obtaining consent during admission. However, the surveyor found that this process was not effectively documented in the residents' medical records, leading to the identified deficiencies.
Failure to Ensure Appropriate Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for two residents, R7 and R25. R7, who has a history of hemiplegia, anxiety disorder, depressive disorder, diabetes mellitus, chronic pulmonary disease, and congestive heart failure, was observed with a bottle of artificial tears and Fluticasone Propionate nasal spray on her over-bed table. Despite having a BIMS score indicating cognitive intactness, there was no self-medication assessment or physician order for R7 to self-administer these medications. The Director of Nursing confirmed that no self-administration assessments were conducted in the facility. R25, diagnosed with discitis, carcinoma in situ of the anus, anemia, Hodgkin lymphoma, and paresthesia, was performing his own perineum wound treatment without an assessment or physician order. R25 was applying a triple antibiotic ointment and a menthol-methyl salicylate cream for pain management without nursing staff oversight. The surveyor noted that the nursing staff was signing off on the treatment administration record as if they had completed the treatments, despite R25 self-administering them. R25 stated that he did not refuse staff assistance, yet the nursing staff claimed he did not allow them to apply treatments. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents who wish to self-administer medications. However, this protocol was not followed for R7 and R25, leading to a deficiency in ensuring the safety and appropriateness of self-medication practices. The lack of proper assessments and documentation highlights a failure in adhering to the facility's self-administration policy, as observed by the surveyor.
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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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