Mercy Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 2727 W Mitchell St, Milwaukee, Wisconsin 53215
- CMS Provider Number
- 525414
- Inspections on file
- 27
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mercy Health Services during CMS and state inspections, most recent first.
A resident on hospice with COPD, a left ischium fracture, and hypertension, who remained full code and had been declining with poor intake and medication refusal, was found unresponsive. The Interim DON assessed the resident as pulseless and apneic, initiated CPR, directed staff to obtain the crash cart, and, with assistance from the ADON and on-site paramedics, continued resuscitative efforts until the resident was pronounced dead and hospice was notified. However, the only entry in the medical record was the time of death per hospice, with no documentation of the assessment or CPR; the Interim DON had instead recorded these details on a risk management form, and the ADON did not document her involvement, resulting in an incomplete and inaccurate medical record.
A resident with dementia and moderate cognitive impairment became agitated and verbally aggressive toward a CNA, who responded by yelling, using threatening language, and raising her fist at the resident. Multiple staff witnessed the incident, and facility leadership confirmed the CNA's actions constituted abuse and intimidation, violating facility policy and the resident's right to be free from abuse.
A resident with moderate cognitive impairment and a history of agitation was verbally threatened by a CNA, who raised her fist and made a threatening statement. Although the incident was promptly reported internally to the Executive Director and DON, the required report to the state survey agency was not submitted within the two-hour timeframe specified by facility policy. Staff interviews confirmed the delay in external reporting of the abuse allegation.
Surveyors found that the facility did not provide required transfer and bed hold notices to residents or their representatives when residents were hospitalized for acute medical conditions. The facility failed to document or deliver written information about the transfer, appeal rights, bed hold policy, or ombudsman contact details, as confirmed by both record review and staff interviews.
Dietary staff did not follow a standardized recipe when preparing pureed breakfast sausage links for three residents on a pureed diet, using unmeasured amounts of thickener and water instead of the specified ingredients. The facility also lacked a current recipe for pureed sausage links, and staff were unclear about the number of residents needing pureed meals, resulting in improper food preparation and potential nutritional concerns.
Two residents receiving antipsychotic medications were not referred for required neurological exams after abnormal AIMS assessment scores. Despite staff acknowledging the need for referral and further evaluation, the necessary follow-up was not completed, and no documentation was found to explain the omission.
A facility failed to investigate a potential misappropriation of medication for a resident with Alzheimer's disease. The resident had an order for Lorazepam, and a discrepancy was found where seven tablets were signed out, but only four were documented as administered. The DON and RNC did not consider misappropriation, focusing instead on documentation issues. The ADON highlighted the importance of proper documentation to prevent double dosing, but the investigation did not address the potential misappropriation, and the nurse involved continued to work without timely education.
A resident with Alzheimer's disease was discharged from a respite stay without all personal belongings, including clothing and a back scratcher. The facility failed to follow its process of using an inventory sheet to ensure all items were returned, resulting in the resident receiving items belonging to another resident. The Administrator acknowledged the issue, indicating a lapse in procedures.
A facility failed to clarify a PRN lorazepam order for a resident with Alzheimer's, leading to confusion in medication administration. The resident's MAR contained conflicting orders for lorazepam, which were not clarified upon admission. The issue was identified after a family member raised concerns, and the DON acknowledged the need for clarification.
A resident in an LTC facility was hit by another resident, resulting in a bruise, but the incident was not reported to the State Survey Agency as required. Despite documentation and monitoring of the bruise, the facility's DON questioned the intent and existence of the bruise, leading to a deficiency noted by the surveyor.
A facility failed to thoroughly investigate two resident-to-resident altercations. In one incident, a resident scratched another, and in another, a resident was hit, resulting in a bruise. The facility did not obtain necessary statements or conduct a root cause analysis for either incident, and one was not reported to the State Survey Agency in time. Despite documentation of a bruise and monitoring for aggressive behavior, the facility did not provide further information to the surveyor.
The facility failed to ensure adequate supervision and fall prevention interventions for two residents, resulting in accidents and injuries. One resident was left unattended despite requiring one-to-one supervision, leading to multiple fractures. Another resident lacked necessary wheelchair safety devices, and staff were unaware of the required interventions.
The facility failed to ensure proper care and prevention of pressure ulcers for two residents. One resident's sacral wound deteriorated to a stage 4 pressure injury due to inadequate assessment and care planning, while another resident's pressure injuries were not comprehensively assessed or properly treated, with incorrect staging and inappropriate dressing.
A resident was administered Furosemide without an assessment for edema, and the medication was not documented in the MAR. The order lacked specific indicators for use, and the LPN did not assess the resident's condition before administration.
A resident was prescribed Buspirone for depressive disorder without a diagnosis of anxiety, and the facility was unaware that the resident was not being followed by psychiatric services. Staff interviews revealed a lack of awareness and proper documentation regarding the resident's diagnoses and medication management.
The facility's medication error rate was 6.9 percent, exceeding the acceptable threshold. An LPN crushed a delayed-release Omeprazole tablet instead of using the prescribed oral suspension and almost administered an inhaler meant for another resident. The errors were identified during a surveyor's observation.
An LPN was observed preparing a resident's medications by popping them into their bare hand before placing them into a med cup. The LPN cited difficulty due to a trigger thumb. The DON was informed and acknowledged the need for education on proper medication pass procedures.
Failure to Document Assessment and CPR Prior to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one hospice resident who was a full code. The resident had COPD, a left ischium fracture, and hypertension, and required maximum assistance for eating and was dependent for toileting and hygiene. After a prior change in condition related to oxygenation and a hospital transfer, the resident was readmitted with hospice services, remained full code, and expressed a desire for comfort measures without further hospitalizations. Nursing notes documented the resident’s gradual decline, refusal of food and medications, and the resident’s wish to avoid further hospitalizations, but the only entry related to the resident’s death was a nurse’s note stating the time of death per hospice at 6:40 p.m., with no documentation of any assessment or actions that preceded the death. Interviews revealed that when the resident was found unresponsive, the Interim DON assessed the resident as having no pulse and no respirations, released the air mattress, and began CPR while directing staff to obtain the crash cart. The ADON returned from lunch, assisted with CPR and application of the AED, and paramedics who were already in the building came to assist and pronounced the resident dead, after which hospice was notified and the hospice nurse officially pronounced death. The ADON did not document any assessment or CPR in the medical record, and the Interim DON documented the assessment and interventions on a facility risk management form instead of in the resident’s medical record. As a result, the resident’s medical record lacked documentation of the assessment and resuscitative efforts that occurred prior to the recorded time of death.
Failure to Protect Resident from Verbal and Mental Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and mental abuse by staff. According to facility policy, abuse includes humiliation, harassment, threats of punishment, or deprivation, and staff are required to prohibit and prevent such actions. The incident involved a resident with moderate cognitive impairment, dementia, and behavioral disturbances, who became agitated and verbally aggressive toward a Certified Nursing Assistant (CNA). In response, the CNA yelled at the resident, used threatening language, and raised her fist in a threatening manner. Multiple staff members witnessed the CNA's actions, including cursing and making threats toward the resident. One staff member intervened by removing the CNA from the situation, and another reported the incident to facility leadership. The resident, who required de-escalation techniques and specific behavioral interventions per their care plan, reported feeling threatened and believed the staff member intended to cause harm. Facility documentation and interviews confirmed that the CNA's behavior constituted abuse and intimidation, as defined by facility policy. The incident was reported to the appropriate authorities, and the CNA was suspended pending investigation. The deficiency was based on the failure of staff to follow established protocols for managing resident behavior and ensuring residents are treated with dignity and respect.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of verbal and mental abuse involving a resident with moderate cognitive impairment and a history of dementia, agitation, and aggression. On the day of the incident, a CNA was observed yelling at and threatening the resident, including raising her fist and making a threatening statement. The incident was witnessed by an LPN, who immediately notified the Executive Director and the DON. The facility's policy required that all allegations of abuse be reported to the state survey agency within two hours of the allegation being made. Despite the policy, the report to the state survey agency was not submitted until more than six hours after the incident occurred. Interviews with facility staff, including the Executive Director and DON, confirmed that the two-hour reporting timeframe was not met. Documentation showed that the incident was recognized as abuse by staff, and the CNA involved was suspended pending investigation. The delay in reporting constituted a failure to follow both facility policy and regulatory requirements for timely reporting of abuse allegations.
Failure to Provide Required Transfer and Bed Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required transfer and bed hold notices to residents and/or their representatives when residents were transferred to the hospital. Multiple residents experienced acute changes in condition, such as chest pain, shortness of breath, seizures, altered mental status, and vomiting, which led to their hospitalization. Despite these transfers, there was no documentation in the medical records that the residents or their representatives received written notification regarding the transfer, the reason for transfer, the location, appeal rights, or contact information for the State Long-Term Care Ombudsman. The facility also did not provide written information on the duration of the bed hold policy, the reserve bed payment policy, or the right to return to the facility. This deficiency was confirmed through interviews with facility leadership, who acknowledged that the process for providing these notices had lapsed due to the responsible staff member being on leave. The facility's own policies require that such notices be given at the time of transfer and that a signed and dated copy be kept in the resident's file, but these procedures were not followed for any of the residents reviewed. The lack of required documentation and notification was consistent across all residents reviewed for hospitalization, with no evidence that any of the affected residents or their representatives received the mandated information. The deficiency was further substantiated by the absence of transfer and bed hold notices in the residents' medical records and by statements from facility leadership confirming the failure to provide these notices.
Failure to Prepare Pureed Foods According to Recipe for Residents on Modified Diets
Penalty
Summary
The facility failed to ensure that food was prepared in accordance with prescribed recipes for residents requiring a pureed diet. During breakfast food preparation, a dietary aide was observed preparing pureed breakfast sausage links without following a standardized recipe. The aide added unmeasured amounts of thickening powder and boiling water to the sausage mixture, rather than using the specified ingredients and measurements. The aide later admitted to forgetting to add gravy, which was intended to enhance the nutritional value of the puree, and instead used boiling water. Additionally, there was confusion among dietary staff regarding the number of residents requiring a pureed diet, with inconsistent responses about the correct number of portions to prepare. Further review revealed that the facility did not have a current recipe for pureed breakfast sausage links, and the recipe provided was for sausage patties instead. The lack of a proper recipe and failure to follow measured preparation methods could impact the nutritional content of the food provided to residents on a pureed diet. These deficiencies were confirmed through staff interviews and direct observation, affecting three residents who required a pureed diet at the time of the survey.
Failure to Refer for Neurological Exams After Abnormal AIMS Scores
Penalty
Summary
The facility failed to ensure that residents receiving antipsychotic medications were adequately monitored for abnormal involuntary movements, as required by their own protocols. Specifically, two residents with diagnoses including dementia, schizophrenia, anxiety, and bipolar disorder were identified as having Abnormal Involuntary Movement Scale (AIMS) assessment scores that necessitated referral for a complete neurological exam. For one resident, an AIMS assessment documented a score of 3 in one body area, which required a neurological referral, but no such referral or exam was found in the medical record. For the other resident, an AIMS score of 5 was recorded, also requiring a referral for a complete neurological exam, but there was no evidence that this referral or exam was completed. Interviews with facility staff, including the President of Success-D, the DON, and an RN, confirmed that the expected process following such AIMS scores was not followed. Staff acknowledged that a referral should have been made and that the provider should have been notified, but this did not occur. The deficiency was identified through record review and staff interviews, with no additional information provided by the facility to explain the lack of follow-through on required neurological assessments.
Failure to Investigate Potential Misappropriation of Medication
Penalty
Summary
The facility failed to investigate a potential misappropriation of medication for a resident during a five-day respite stay. The resident, who was severely cognitively impaired with a diagnosis of Alzheimer's disease, had an order for Lorazepam to be administered as needed for anxiety or restlessness. On one occasion, seven Lorazepam tablets were signed out, but only four were documented as administered in the Medication Administration Record (MAR). This discrepancy was not investigated as a potential misappropriation of medication. The Director of Nursing (DON) and the Regional Nurse Consultant (RNC) did not consider the possibility of misappropriation, focusing instead on the lack of documentation by the nurse responsible. The Assistant Director of Nursing (ADON) emphasized the importance of documenting narcotic administration in both the Resident Controlled Substance Record and the MAR to prevent double dosing. Despite the concerns raised by the resident's family, the investigation did not address the potential misappropriation, and the nurse involved continued to work without receiving timely education on proper documentation practices.
Failure to Protect Resident's Personal Belongings
Penalty
Summary
The facility failed to exercise reasonable care for the protection of personal items for a resident who was admitted for a five-day respite stay. Upon discharge, the facility was unable to return all of the resident's personal belongings, including clothing and a back scratcher, which were brought in at the time of admission. The resident, who had a diagnosis of Alzheimer's disease and was severely cognitively impaired with a BIMS score of 2/15, was unable to advocate for himself, leading to his family member contacting the facility to report the missing items. Interviews with Certified Nurse Aides revealed that they typically use an inventory sheet to ensure residents leave with all their personal items, highlighting the importance of this process. However, in this case, the process was not effectively followed, resulting in the resident receiving some items belonging to another resident. The facility's Administrator acknowledged the issue and confirmed that not all items were returned at the time of discharge, indicating a lapse in the facility's procedures for managing residents' personal belongings.
Failure to Clarify PRN Lorazepam Order
Penalty
Summary
The facility failed to clarify a physician's order for as-needed lorazepam, a controlled anti-anxiety medication, for a resident during their respite stay. The resident, who was admitted with a diagnosis of Alzheimer's disease and had a severely impaired cognitive status, had two conflicting orders for lorazepam in their Medication Administration Record. One order was for a single 0.5mg tablet every four hours as needed for anxiety or restlessness, while the other allowed for two tablets with specific instructions if the first tablet was ineffective. This discrepancy led to confusion in medication administration. The issue was identified when the resident's family member raised concerns about the amount of lorazepam administered. Upon investigation, the Director of Nursing acknowledged the confusion caused by the unclear orders and confirmed that the orders should have been clarified upon the resident's admission. The Regional Nurse Consultant also confirmed the need for clarification of the orders, emphasizing the importance of obtaining a standard dose order to prevent such confusion.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation to the State Survey Agency within the required timeframe. On July 14, 2024, a resident identified as R2 was hit on the left forearm by another resident, R9, resulting in a bruise. Despite the incident being documented by staff, including notifications to the Director of Nursing, physician, and other relevant parties, the facility did not report the altercation to the State Survey Agency as mandated by their policy. R2, who has a history of cognitive impairments and behavioral issues, was admitted with multiple diagnoses including hemiplegia, epilepsy, and schizophrenia. R2's care plan included interventions for managing anxiety and aggression, and the resident was noted to have severely impaired decision-making skills. The altercation with R9, who also has significant medical conditions including dementia, was documented in R2's progress notes, indicating a bruise on the left forearm that was monitored by nursing staff. Despite the documentation of the incident and the resulting bruise, the Director of Nursing later stated that the team did not believe there was intent to harm and questioned the existence of the bruise. This discrepancy and the failure to report the incident to the State Survey Agency within the required timeframe were noted by the surveyor, who found no additional information provided by the facility to justify the lack of timely reporting.
Incomplete Investigation of Resident Altercations
Penalty
Summary
The facility failed to ensure thorough investigations of two resident-to-resident altercations involving four residents. The first incident involved a resident, R2, scratching another resident, R3, on the forearm. The facility submitted a Misconduct Incident Report but did not complete a thorough investigation, as it lacked staff statements, other resident statements, and a root cause analysis of the altercation. The report was also missing a page, indicating incomplete documentation. The second incident involved R9 hitting R2 with a closed fist, resulting in a bruise on R2's left forearm. The facility did not obtain necessary staff statements, other resident statements, or conduct a root cause analysis for this altercation either. Despite documentation in R2's progress notes indicating a bruise and monitoring for aggressive behavior, the facility did not report the incident to the State Survey Agency within the required timeframe. The Director of Nursing (DON) stated that the team did not feel there was intent to harm, and no further information was provided to the surveyor. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and thorough documentation of alleged violations, including identifying and interviewing all involved persons and conducting a root cause analysis. However, these procedures were not followed in the cases of R2's altercations with R3 and R9. The surveyor noted the lack of thorough investigation and documentation, and despite being informed of these concerns, the facility did not provide additional information or justification for the incomplete investigations.
Failure to Implement Fall Prevention Interventions and Adequate Supervision
Penalty
Summary
The facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for two residents. Resident 1 (R1) was assessed to require one-to-one staff supervision but was left unattended, resulting in a fall that caused multiple fractures. Observations revealed that R1 did not have the fall prevention interventions, such as anti-roll back equipment or a fall mat, as documented in the care plan. The incident occurred when the assigned staff member left R1 unattended to use the restroom, contrary to the facility's one-to-one supervision policy. Additionally, R1's care plan interventions, such as keeping the bed in a low position and using a fall mat, were not consistently followed, as observed during the surveyor's visit. Resident 2 (R2) was observed to lack current fall prevention interventions, including auto lock brakes and Dycem under the wheelchair cushion, as specified in the care plan. R2's care plan included several interventions to prevent falls, but these were not in place during the surveyor's observation. Interviews with staff revealed a lack of awareness and implementation of these interventions. The maintenance director confirmed that there was no record of the required devices being requested or installed for R2's wheelchair. The facility's policy on accidents and supervision emphasizes the importance of implementing specific interventions to reduce residents' risks from environmental hazards and providing adequate supervision based on individual needs. However, the facility failed to adhere to these policies, resulting in accidents and injuries for the residents. The lack of proper supervision and failure to implement care plan interventions contributed to the deficiencies observed during the survey.
Failure to Prevent and Properly Treat Pressure Ulcers
Penalty
Summary
The facility did not ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and to ensure residents do not develop new pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. This affected two residents reviewed for pressure injuries. One resident was admitted with three stage 3 pressure injuries, but the facility did not comprehensively assess these areas upon admission. The sacral wound deteriorated to a facility-acquired unstageable pressure injury that became a stage 4 pressure injury due to the continual need for debridement. The facility did not make timely revisions to the resident's care plans to address the ongoing deterioration of the sacral pressure injury and to assist in healing. Another resident developed two facility-acquired pressure injuries that were not comprehensively assessed. The facility assessed one area to be a stage 2 pressure injury with the presence of granulation, which was an incorrect stage. During observations, it was noted that the resident had two open areas on the buttocks that were not comprehensively assessed or properly treated. The areas were observed with one large piece of gauze covering both areas, which is not what the physician ordered. The facility did not clarify treatment orders for each of the areas of pressure injury on the resident's buttocks. The facility's policy on pressure injuries and non-pressure injuries was not followed. The policy required a comprehensive assessment to identify risk factors for the development of pressure injuries and to put in place measures intended to achieve the goal of prevention. For residents admitted with or who subsequently developed a pressure injury, they were to receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries. The facility failed to adhere to these guidelines, resulting in inadequate care and worsening of pressure injuries for the affected residents.
Failure to Assess and Document PRN Medication Administration
Penalty
Summary
The facility did not ensure medications were administered to meet the needs of a resident observed receiving as-needed medications. Specifically, a resident was administered Furosemide, a diuretic, without an assessment to determine if the medication was indicated. The order for Furosemide did not include any parameters or physical indicators for when the medication should be administered. The Licensed Practical Nurse (LPN) administered the medication without assessing the resident for edema, which was the condition the medication was prescribed for. Additionally, the administration of the medication was not documented in the Medication Administration Record (MAR). The resident had an order for Furosemide 40 mg every 24 hours as needed for edema, but the order lacked specific indicators for use. The LPN did not assess the resident's leg or stump for swelling before administering the medication. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were informed of the issue, and the DON acknowledged the need for staff education regarding medication administration. The deficiency was observed during a surveyor's visit, and it was noted that the medication was not signed out in the MAR, indicating a lapse in proper documentation and assessment procedures.
Deficiency in Medication Management and Diagnosis Documentation
Penalty
Summary
The facility did not ensure that a resident on psychotropic medications had a proper diagnosis for the use of the medication and was being followed for medication management. The resident, identified as R20, was prescribed Buspirone, an antianxiety medication, for depressive disorder without a diagnosis of anxiety. The facility was unaware that R20 was not being seen by the outpatient mental health clinic until the surveyor brought it to their attention during the survey. The resident's medical records indicated that R20 was cognitively intact and was being monitored by nursing staff for psychotropic medication use without adverse reactions or complications. R20 had multiple diagnoses, including cerebrovascular accident, seizures, diabetes, depression, and alcohol and tobacco abuse. The resident was admitted with orders for Duloxetine, Trazodone, and Buspirone. A progress note from an outpatient mental health clinic visit indicated that R20 had anxiety, depression, and alcohol use, and recommended changes to the medication regimen. However, the facility's records did not list anxiety as a diagnosis, and the Social Services Director (SSD) and Director of Nursing (DON) were not aware of the discrepancy or that R20 was not being followed by psychiatric services. Interviews with facility staff revealed that the SSD and DON were not aware of the resident's current psychiatric follow-up status or the correct diagnoses for the medications prescribed. The Licensed Practical Nurse (LPN) responsible for Minimum Data Set (MDS) assessments stated that diagnoses are entered based on hospital discharge summaries and physician orders, but was unable to find any information regarding the diagnosis of anxiety for R20. The surveyor shared these concerns with the Nursing Home Administrator (NHA), who acknowledged the issues but did not provide further information at that time.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility did not ensure the medication error rate was below 5 percent, resulting in a medication error rate of 6.9 percent. During a medication pass, an LPN crushed an Omeprazole delayed-release tablet and administered it through a resident's gastrostomy tube, despite the medication order specifying an oral suspension. This action rendered the medication ineffective. Additionally, the LPN almost administered an inhaler prescribed for a different resident, which was only prevented by the surveyor's intervention. The resident involved had an order for Omeprazole oral suspension to manage gastroesophageal reflux disorder (GERD). The LPN admitted to not having the oral suspension available and planned to contact the pharmacy. The Director of Nursing acknowledged the issues and indicated a need for further education on medication administration for the nursing staff.
Sanitary Practices Not Maintained During Medication Pass
Penalty
Summary
The facility did not ensure sanitary practices were maintained during medication pass for one resident. An LPN was observed preparing the resident's morning medications by popping each medication out of the blister pack into the LPN's bare hand before placing them into a medication cup. Additionally, the LPN took a stock medication bottle, shook the medications into their bare hand, replaced extra doses back into the bottle, and put one pill into the med cup. The LPN explained that due to a trigger thumb, it was sometimes difficult to punch the medication out directly into the med cup. The Director of Nursing was informed of the observation and acknowledged the need for education on proper medication pass procedures.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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