Middleton Village Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Middleton, Wisconsin.
- Location
- 6201 Elmwood Ave, Middleton, Wisconsin 53562
- CMS Provider Number
- 525330
- Inspections on file
- 39
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Middleton Village Nursing And Rehab during CMS and state inspections, most recent first.
A facility did not report an allegation of sexual abuse involving a resident and a CNA to the state agency within the required timeframe. Although the incident was investigated internally and staff were educated on the abuse policy, the mandated report was not submitted as required by facility policy.
A resident's family member elevated a grievance to an allegation of sexual abuse by a CNA, but the facility did not conduct a thorough investigation or report the findings to the state agency within the required timeframe. The CNA continued working during the investigation, and the facility did not follow its abuse policy for immediate protection and timely reporting.
Surveyors found that food preparation, storage, and serving areas were not maintained in a clean and sanitary manner, with dirty meal trays left in the dining room, non-functional hand sanitizer dispensers, cluttered and unclean dish room surfaces, an unclean microwave, uncovered and undated butter, and stained walls and curtains. Dietary staff and management confirmed these practices did not follow facility policies.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with a kitchen door left detached for months, meal trays left in resident rooms after meals, and shower rooms observed to be cluttered, unclean, and in disrepair. Staff and management were aware of these issues, and residents expressed discomfort with the conditions.
The facility did not report two separate allegations of abuse—one involving an alleged sexual abuse and another involving a verbal threat—within the required timeframe to the State Agency or law enforcement, despite both incidents being recognized by staff and administration as reportable under facility policy.
A resident reported that another resident made a threatening statement, which was disclosed to therapy staff and subsequently reported to the NHA. The facility's investigation was incomplete, lacking interviews with involved staff and other residents, and missing key documentation. The NHA acknowledged the investigation was not thorough, as required.
A resident with multiple neurological and psychiatric diagnoses did not have consistent or documented checks of their elopement device's function. Staff interviews revealed confusion and inconsistency regarding how and how often to check the device, with some staff unaware of the correct procedure or equipment. The facility's policy did not address functional monitoring of the device, resulting in inadequate supervision to prevent accidents.
A resident with multiple medical conditions did not have two doses of thyroid medication documented as administered, with blank entries on the MAR. Staff interviews revealed inconsistent understanding of documentation procedures, and facility policy requiring proper documentation was not followed, resulting in an inability to verify if the medication was given.
The facility failed to provide necessary care for residents, resulting in harm and potential harm. A resident with a tooth abscess did not receive timely antibiotics, leading to increased pain and infection. Another resident's breast blisters were not properly assessed or treated, worsening the condition. Additional issues included inadequate care planning for a resident on chemotherapy and incomplete wound care documentation. These deficiencies highlight lapses in care, communication, and documentation.
A resident developed a stage 3 pressure injury due to inadequate care and prevention measures. The facility delayed providing an appropriate mattress and failed to perform wound care per physician orders. Observations showed the resident lying directly on the wound and with heels in contact with the mattress. Documentation and communication regarding the wound were insufficient, with missing measurements and descriptions in the medical record.
A resident experienced severe breakthrough pain due to the facility staff's failure to administer prescribed PRN pain medication for five hours, despite its availability in contingency stock. The resident, who was cognitively intact and had a history of serious health conditions, reported a pain level of 9 out of 10. The facility's pain management policy was not followed, as there was a lack of timely response and documentation of non-pharmacological interventions. Communication gaps and procedural failures among staff contributed to the deficiency.
The facility failed to maintain food safety standards, with moldy food found in a resident's room and improperly labeled food items in the kitchen. A resident stored perishable food at room temperature, and housekeeping staff had previously reported moldy food to nursing staff, but the DON was unaware. Additionally, an ice scoop was improperly stored inside the ice machine, posing a cross-contamination risk.
The facility did not ensure proper disposal of garbage and refuse, potentially affecting all 75 residents. Surveyors observed the main dumpster with its lid open and various items improperly discarded on the ground, including surgical masks, condiment packets, used disposable gloves, and scattered cardboard. The Dietary Manager acknowledged the issue and stated it would be addressed immediately.
The facility failed to conduct timely and thorough background checks for a Medication Technician and two CNAs, as required by their policies. The checks were either outdated or incomplete, lacking necessary documentation such as Wisconsin results and unanswered BID questions. Interviews confirmed that these checks should occur every four years, but this was not followed.
A resident was administered psychotropic and antipsychotic medications without an appropriate diagnosis or proper informed consent. Verbal consent was obtained but not followed by signatures, contrary to facility policy. Staff interviews confirmed the lack of adherence to policy and regulatory guidance.
A medication error rate of 7.69% was identified in a facility, exceeding the acceptable 5% threshold. An LPN administered an incorrect dose of calcium carbonate and omitted Pyridoxine HCl for a resident, citing a likely transcription error and unavailability in contingency stock. The DON confirmed that medications should follow physician orders.
A resident with limited mobility was not walked according to their care plan, which required ambulation assistance twice daily. Despite the resident's cognitive intactness and medical conditions, facility documentation showed multiple days without walking, and no refusals were recorded. Interviews with staff revealed inconsistencies in following the walking program, with some staff unaware of refusals and others not prompting the resident to walk.
A CNA in a long-term care facility failed to follow proper infection control procedures by not changing gloves or washing hands after assisting a resident and before handling clean linens. Additionally, a resident's room was found with soiled linens on the floor and a strong odor of urine, highlighting a breach in maintaining a sanitary environment.
The facility failed to implement an effective emergency training program, leaving staff unprepared for a severe weather event and power outage. Staff were unable to identify emergency outlets and had not received training on handling such emergencies, leading to a chaotic response and difficulties in providing necessary care to residents.
A resident with dysphagia, aphasia, and intellectual disability had two conflicting enteral feeding orders being signed out as administered, and the feeding bottle lacked proper labeling. The facility policy was not followed, leading to potential risk for the resident's care.
The facility failed to obtain and transcribe CPAP orders upon admission for two residents with obstructive sleep apnea. One resident's CPAP order was delayed by over two years, while another went 43 days without the necessary order, leading to an emergency room visit during a power outage. The DON confirmed that CPAP orders should have been present from admission.
The facility failed to report an incident of verbal abuse involving a resident with moderate cognitive impairment. Despite a CNA reporting the abuse, the Director of Nursing and the Nursing Home Administrator were unaware of the incident and did not report it to the necessary authorities as required by policy.
A facility failed to investigate and report an allegation of verbal abuse involving a resident with moderate cognitive impairment. Despite the incident being reported by a CNA, the facility did not follow its policy to investigate and report the incident to the state agency.
The facility failed to ensure that three residents received scheduled showers, leading to concerns about personal hygiene. Residents reported missed showers due to staff shortages and incorrect documentation of refusals. The Director of Nursing confirmed that scheduled showers were not completed or properly documented.
The facility failed to provide adequate care and monitoring for three residents. One resident with a history of aspiration pneumonia was not properly care planned or assessed despite non-compliance with dietary recommendations. Another resident experienced episodes of constipation due to inadequate monitoring of bowel movements and unmet dietary needs. A third resident did not receive wound care as ordered, with lapses in documentation and treatment.
A resident with Type 2 Diabetes Mellitus was admitted with orders for POCT glucose testing four times daily, but the facility failed to monitor the resident's blood glucose levels. The resident's MAR did not include the glucose monitoring order, and the DON confirmed that the monitoring was not conducted as required.
A resident with multiple diagnoses did not receive her prescribed doses of amlodipine, ezetimibe, and carbamazepine. The facility's policies require timely administration and documentation of medications, but the medications were not given, and no explanation was documented. Interviews with staff confirmed the process for obtaining unavailable medications, but the medications were still not administered as ordered.
A resident with a history of cerebral infarction, dementia, and mobility issues eloped twice despite wearing a WanderGuard device and being identified as an elopement risk. During the second incident, staff did not respond promptly to the alarm, reset it without verifying the resident's location, and delayed notifying law enforcement. The resident was later found 1.5 miles away. The facility's policies lacked specific guidance on timely law enforcement notification and ensuring door alarms remain active until the resident is located, contributing to the Immediate Jeopardy finding.
A resident, who was cognitively intact, reported feeling violated when an LPN physically grabbed their arm and removed a dab/vape pen from their hand. The incident was corroborated by multiple staff members, but the DON did not initially report or investigate it until later informed. The facility's policy mandates protections against such actions.
A resident with multiple sclerosis, bipolar disorder, and anxiety disorder alleged that an LPN physically grabbed his arm and removed a dab/vape pen from his hand. Despite the facility's policy requiring immediate reporting of such incidents, the Director of Nursing did not report the allegation to the State Agency until several days later, after becoming fully aware of the resident's claims.
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident and an LPN. The incident involved the LPN allegedly grabbing the resident's arm and forcibly removing a dab/vape pen from the resident's hand. Conflicting accounts from staff and the resident were not promptly investigated, leading to a deficiency in protecting the resident from potential abuse.
A facility failed to ensure a resident was using a CPAP machine as ordered by the physician. The resident, who was cognitively intact, confirmed the absence of the CPAP machine. An LPN and the DON acknowledged that the machine was not available and the physician was not notified.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframes. Specifically, an allegation of sexual abuse was made by a family member, who reported to the Nursing Home Administrator (NHA) that a CNA had inappropriately touched a resident's private area during routine care. The facility became aware of this allegation on 9/23/25 and conducted an internal investigation, including staff interviews and education on the abuse policy, which concluded on 9/30/25. Despite the facility's policy requiring immediate reporting of such allegations to the state agency, the incident was not reported as required. As of 10/8/25, a report had still not been submitted to the state agency. During an interview on 10/8/25, the NHA acknowledged that the incident should have been reported to the state agency on the day the allegation was made, in accordance with the facility's abuse policy and the education she had received.
Failure to Investigate and Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of sexual abuse involving a resident. A family member initially raised a concern regarding peri care performed by a CNA without gloves, which was documented as a grievance. This concern was later elevated to an allegation of inappropriate touching of the resident's vaginal area by the same CNA. Despite the escalation to a sexual abuse allegation, the facility did not conduct additional interviews or expand the investigation, and the CNA continued to work with residents during the investigation period. The facility's abuse policy requires immediate protection of the alleged victim, thorough investigation, and timely reporting to the state agency, but these steps were not fully followed. Furthermore, the facility did not submit the required report of the investigation's findings to the state survey agency within the mandated five working days. Documentation shows that the CNA remained on duty after the allegation was made, and education on abuse policies was not completed until several days later. The administrator acknowledged that the incident should have been reported to the state agency when the allegation was elevated, but this was not done in accordance with facility policy and state law.
Failure to Maintain Sanitary Food Preparation and Storage Practices
Penalty
Summary
The facility failed to ensure the preparation, storage, and serving of food in a clean and sanitary environment, as evidenced by multiple observations during the survey. Partially eaten meal trays from a previous meal were left on tables in the dining room while residents were eating breakfast. Three wall-mounted hand sanitizer dispensers in the dining room were found to be non-functional. In the dish room, a table was cluttered with stacked cardboard boxes, a tray of glasses, a dirty towel, dirty coffee pots, a fleece jacket, and a metal pot inside a box of aprons, all in violation of facility policy regarding food storage and cleanliness. Additionally, the inside of the kitchen microwave was observed to be covered with dried, multi-colored splatters, indicating it had not been cleaned as required by the facility's cleaning schedule. Further observations included an opened package of butter left uncovered and undated on a cart by the stove, and multi-colored stains on the walls near the dish room entrance and on a curtain by the garbage in the dining room. Interviews with dietary staff and the dietary manager confirmed that these cleaning and storage practices did not align with facility policies, which require all foods to be stored covered, labeled, and dated, and for storage areas to be kept neat and clean. The dietary manager acknowledged the deficiencies and indicated awareness of the required procedures.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to provide a safe, clean, comfortable, and homelike environment for residents, as required by policy. In the kitchen, a door connecting the dish room and main dining room was found detached from its hinges and leaning against the kitchen sink for an extended period. Staff interviews and email records revealed that the issue had been ongoing for several months, with maintenance and management aware of the problem but unable to resolve it due to delays in ordering a replacement door. The lack of a functioning door raised concerns about sanitation and potential cross-contamination between the kitchen and dining areas. In resident rooms, meal trays were observed left unattended after residents had finished eating and left the room. Interviews with staff indicated that tray removal was based on resident preference, but at least one resident expressed discomfort with trays being left in her room. This practice did not align with maintaining a clean and homelike environment for residents. The facility's shower rooms were found to be cluttered, unclean, and not homelike. Observations included multiple lifts and shower chairs stacked in the rooms, unlabeled and open bottles of skin and hair cleanser, dust, stained items, and personal belongings left out. In one shower room, a ceiling tile was dripping water, and the shower was not fully functional, with a missing handle and water leaking from the area. Staff interviews confirmed awareness of these issues, and both the DON and NHA agreed that the shower rooms were neither clean nor homelike. Additional observations in another shower room included a dirty toilet, a commode bucket with dried residue, lack of hand sanitizer, and soiled towels and sponges left out.
Failure to Timely Report Alleged Abuse and Threats
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by policy. In one instance, a resident's Power of Attorney (POA) reported an alleged sexual abuse incident involving a staff member, but the facility did not report this allegation to the State Agency or law enforcement, despite the administrator acknowledging that the allegation met the definition of sexual abuse and was a reportable incident. Documentation showed that the concern was initially treated as a grievance, and while an internal investigation was conducted, the required external reporting did not occur. In another case, a cognitively intact resident reported to therapy staff that another resident made a threatening statement, which was recognized by staff and administration as verbal abuse and a reportable incident. However, this allegation was also not reported to the State Agency within the required timeframe. The facility's own policy defined such statements as verbal abuse and required immediate reporting, but the incident was only documented as a grievance without evidence of timely external notification.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
A cognitively intact resident (R5), as indicated by a BIMS score of 13, reported that another resident (R9) made a threatening statement to her, saying, "If I had a gun, I'd shoot you." R5 did not report the incident immediately but disclosed it during a therapy session the following day to an occupational therapist (OT K), who stated she would report it to the nursing home administrator (NHA A). Both OT K and a physical therapist (PT L), who was present during the disclosure, confirmed they were not interviewed or asked to provide statements regarding the incident. The facility's investigation was limited to a grievance form that lacked critical details, such as the name of the resident who made the comment, the staff who reported the allegation, and documentation of interviews with staff or other residents. The NHA acknowledged that the incident was considered an allegation of abuse and that the investigation process was initiated. However, the investigation did not include interviews with other staff or residents to determine if similar threats had been made by R9 to others. The only actions taken were speaking with R9, who denied intent and acknowledged the inappropriateness of the comment, and searching R9's room. The NHA admitted that the investigation was not thorough, as required by facility policy and regulatory expectations.
Failure to Ensure Consistent Monitoring of Elopement Device Function
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically regarding the monitoring of an elopement device. The resident in question had multiple diagnoses, including cerebral infarction, intracerebral hemorrhage, psychosis, mood disorder, substance abuse, anxiety disorder, personality disorder, and encephalopathy. Although there was a physician's order to check the placement and location of the wander device, there was no order or documentation in the treatment authorization request (TAR) to check the function of the device. The facility's Elopement/Unsafe Wandering Policy and Procedure did not address monitoring the function of the elopement device. Interviews with nursing staff and facility leadership revealed inconsistent knowledge and practices regarding how and how often to check the function of the wander device. Some staff were unaware of the correct procedure or equipment to use, while others provided varying answers about the frequency of checks, ranging from every shift to daily or only on the night shift. The Director of Nursing stated that all nurses should know how to check the function of the device and that it should be done every shift, but this was not reflected in staff responses or in facility policy. This lack of clear guidance and consistent practice led to the deficiency in ensuring the resident's safety from accident hazards.
Failure to Document and Verify Medication Administration
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services that meet the needs of each resident, specifically in the accurate administration and documentation of medications. For one resident with multiple diagnoses, including hypothyroidism, the Medication Administration Record (MAR) showed two blank entries for scheduled doses of levothyroxine, a thyroid medication. Facility policy requires that medications be administered as ordered and that the MAR be initialed after each administration. However, on two separate dates, there was no documentation to confirm whether the medication was given. Interviews with facility staff, including the Director of Nursing, Infection Preventionist, and several LPNs, revealed uncertainty and inconsistency regarding the meaning of blank boxes on the MAR. Staff responses indicated that a blank could mean the medication was not given, not documented, or simply not checked off, and there was no way to verify administration in these instances. The lack of documentation and clarity among staff led to the inability to confirm that the resident received their prescribed medication as ordered.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for several residents, resulting in actual harm for two residents and potential harm for others. One resident with a tooth abscess did not receive prescribed antibiotics in a timely manner, leading to increased pain and infection. The facility did not monitor or assess the resident's oral condition adequately, despite clear signs of infection and repeated complaints of pain. Another resident developed blisters on her breast, which were not properly assessed or treated, leading to deterioration and infection. The facility failed to implement preventative measures and did not document or assess the wound consistently. The resident's care plan was not updated to address the risk factors contributing to the wound, and there was a lack of communication with therapy staff regarding potential causes and solutions. Additional deficiencies included the lack of care planning for a resident undergoing chemotherapy, incomplete wound care documentation for two residents, and inadequate assessment and monitoring of residents sent to the hospital. These failures highlight significant lapses in the facility's ability to provide appropriate and timely care, as well as a lack of effective communication and documentation practices.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, identified as R41, who developed an in-house acquired stage 3 pressure injury on her coccyx. The surveyor observed R41 lying directly on her wound and with her heels in direct contact with the mattress multiple times during the survey. The facility delayed changing R41's bed to a mattress designed to treat stage 3 or higher pressure injuries and did not perform wound care according to physician orders. The facility's policy on pressure injury and skin integrity was not followed, as interventions to mitigate the risk of skin breakdown were not consistently documented or implemented. R41 was admitted to the facility with multiple diagnoses, including morbid obesity, muscle weakness, and heart disease. Her comprehensive care plan included interventions to prevent skin impairment, such as applying barrier cream and ensuring heels were elevated while in bed. However, the treatment administration record showed several instances where these interventions were not completed or documented. Additionally, the facility's use of double briefs, which is not a standard of practice, increased the risk of pressure injuries due to excessive moisture. The facility's documentation and communication regarding R41's pressure injury were inadequate. There were no measurements or descriptions of the wound in the medical record, and the facility failed to notify the primary care physician when the wound opened or changed. The nurse practitioner noted that the wound was a stage 3 pressure injury with 100% slough, which should have been classified as unstageable. Despite the presence of the wound, the facility did not provide an air mattress until several days after the injury was identified, and staff did not consistently ensure that R41's heels were floated or that she was not lying directly on her wound.
Failure in Pain Management for Resident
Penalty
Summary
The facility staff failed to provide appropriate pain management for a resident, identified as R26, who was experiencing severe breakthrough pain. Despite R26's comprehensive care plan indicating a need for both pharmacological and non-pharmacological interventions, the staff did not administer the prescribed PRN pain medication for a period of five hours. This lapse occurred even though the medication was available in the facility's contingency stock. R26, who was cognitively intact and had a history of conditions such as Acute on Chronic Diastolic Heart Failure and Chronic Obstructive Pulmonary Disease, reported a pain level of 9 out of 10, indicating severe discomfort. The deficiency was further compounded by the lack of individualized non-pharmacological interventions in R26's care plan, and there was no documentation of such interventions being performed. Observations and interviews revealed that R26 was visibly in pain, exhibiting signs such as wincing and crying, yet the staff failed to respond promptly to her requests for pain relief. The facility's policy on pain management, which requires regular assessment and documentation of pain and its management, was not adhered to, as evidenced by the delayed response to R26's pain complaints. Interviews with facility staff, including a CNA, LPN, and an agency RN, highlighted communication gaps and procedural failures in accessing and administering the contingency stock medication. The Director of Nursing confirmed that the facility had the necessary medication in stock and that licensed nurses were expected to access it when needed. However, the staff's failure to do so resulted in R26 enduring severe pain unnecessarily, reflecting a significant deficiency in the facility's pain management practices.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed during the survey. In one instance, a cognitively intact resident was found to have moldy food in her room, including grapes with visible mold and other perishable items stored at room temperature. The resident admitted to ordering food via Door Dash and storing it improperly. Housekeeping staff had previously noticed moldy food in the resident's room and reported the issue to nursing staff, but the Director of Nursing (DON) was unaware of these reports. Additionally, there was uncertainty about whether Door Dash deliveries were being taken directly to residents' rooms or left at the front desk. Further deficiencies were noted in the facility's kitchen and nourishment room, where several food items were found without proper labeling, including opened bags of baking powder, cake mix, gravy mix, and dry macaroni, as well as an opened gallon of milk and a tube of Braunschweiger without open dates. The Dietary Manager was unsure of when these items were opened and agreed to discard them. Additionally, an ice scoop was found inside the ice machine, posing a risk of cross-contamination, which the Dietary Manager acknowledged should not occur.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, which has the potential to affect all 75 residents. On the morning of October 21, 2024, surveyors observed the main dumpster outside the facility with its lid open. Surrounding the dumpster were various items improperly discarded on the ground, including surgical masks, sealed condiment packets, pre-made condiment containers with lids, numerous used disposable gloves, plastic straws and plasticware, paper towels, and scattered pieces of cardboard. During an interview conducted shortly after the observation, the Dietary Manager (DM Y) acknowledged the situation, stating that the facility attempts to maintain cleanliness in the area whenever garbage is taken out. The manager also indicated that the area should be cleaned up and assured that it would be addressed immediately.
Failure to Conduct Timely and Thorough Staff Background Checks
Penalty
Summary
The facility failed to ensure that staff background checks were completed thoroughly and timely for three out of eight staff members reviewed. Specifically, the background information disclosure (BID) checks for a Medication Technician and two Certified Nursing Assistants (CNAs) were not conducted as required. The Medication Technician's BID had not been updated since the initial check in December 2019, and the CNA's BID had not been updated since November 2019, lacking the necessary Wisconsin results. Additionally, the BID for another CNA was incomplete, with no questions answered on the document. The facility's policies and procedures require that background checks, including re-checks, be conducted every four years and include specific documentation such as a Department of Justice response letter and governmental findings report. However, these requirements were not met for the staff members in question. Interviews with the Human Resources representative and the Nursing Home Administrator confirmed that background checks should be completed every four years and include all necessary documentation, but this was not adhered to in these cases.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication was free from unnecessary medication. The resident, identified as R23, was administered psychotropic and antipsychotic medications without an appropriate diagnosis for the antipsychotic medication. The facility's policy on Psychotropic Medication Management requires that residents should not receive unnecessary medications unless non-pharmacological interventions have failed. However, R23 was prescribed quetiapine for dementia with behaviors, which was acknowledged by the LPN and DON as an inappropriate diagnosis for such medication. Additionally, the facility did not obtain proper informed consent before administering these medications. Verbal consent was obtained from the resident's Activated Power of Attorney for Health Care (APOA-HC) for medications including duloxetine, quetiapine, and hydroxyzine, but no follow-up signatures were obtained. The facility's policy mandates that informed consent, including the explanation of risks and benefits, should be documented and signed. The absence of signatures on the verbal consents was confirmed by both the LPN and DON during interviews. The surveyor's interviews with facility staff revealed that the facility did not adhere to its own policy or regulatory guidance regarding the administration of psychotropic medications. The Nursing Home Administrator acknowledged that the facility's policy did not specify a time frame for obtaining signatures on verbal consents, but agreed that it should be done within two weeks. The lack of appropriate diagnosis and failure to obtain signed informed consent before medication administration were the primary deficiencies identified in this report.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 7.69%, exceeding the acceptable threshold of 5%. This was identified during a medication pass task involving 12 residents, where 2 errors were observed out of 26 opportunities. Specifically, a resident, referred to as R477, was affected by these errors. The errors included the administration of an incorrect dose of calcium carbonate and the omission of Pyridoxine HCl. The Licensed Practical Nurse (LPN) responsible for the medication pass administered a 500 mg tablet of calcium carbonate instead of the prescribed 600 mg, and failed to administer the Pyridoxine HCl due to its unavailability in the contingency stock. During interviews, the LPN acknowledged the errors, attributing the incorrect calcium carbonate dosage to a likely transcription error and the omission of Pyridoxine HCl to its unavailability. The Director of Nursing (DON) confirmed that medications should be administered according to physician orders and acknowledged the transcription error as well. The facility's policy on administering medications emphasizes the importance of following physician orders and administering medications safely and timely, which was not adhered to in this instance.
Failure to Implement Resident's Walking Program
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. The resident, who is cognitively intact and has diagnoses including Type 2 diabetes, atherosclerotic heart disease, respiratory failure, chronic pain syndrome, and morbid obesity, was not walked in accordance with his care plan. The care plan required CNAs to assist the resident to ambulate once during each AM and PM shift using a two-wheeled walker, gait belt, and wheelchair to follow. However, facility documentation showed that the resident was not walked on multiple occasions, and no refusals were documented. Interviews with facility staff revealed inconsistencies in the implementation of the resident's walking program. The resident expressed that he was not walked frequently and was unsure if it was his responsibility to ask for assistance. A CNA mentioned it had been weeks since she saw the resident walk, and a Medication Technician stated that the resident often refused to walk but was not always asked. The LPN was unaware of any refusals being reported, and the DON acknowledged that refusals should be documented and reported to a nurse, but it was unclear if the walking plan was being followed.
Infection Control Lapse in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) and the condition of a resident's room. The CNA was observed wearing the same pair of gloves while assisting a resident and then handling clean linens without changing gloves or performing hand hygiene. This action was contrary to the facility's hand hygiene policy, which requires staff to remove gloves and wash hands after resident contact and before handling clean items. Additionally, the resident's room was found to have a strong odor of urine, with soiled linens improperly stored on the floor, which the Licensed Practical Nurse (LPN) confirmed should not have occurred. The resident involved expressed concerns about the cleanliness of her room, which was corroborated by the surveyor and LPN who observed the unsanitary conditions. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that the CNA should have removed gloves and washed hands after assisting the resident and before handling clean linens. They also confirmed that dirty linens should not be stored on the floor, indicating a lapse in adherence to infection control protocols.
Failure to Implement Effective Emergency Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective emergency training program for all facility and contracted staff. This deficiency was evident as eight facility staff and one contracted staff had not received training on electric power outages and emergency outlets. Additionally, staff were not trained on emergency procedures for severe thunderstorms or tornado warnings. This lack of training was highlighted during a severe weather event when the facility lost electrical power, and the emergency generator was activated. Staff were observed to be unprepared and struggled to manage the situation effectively, as evidenced by their inability to identify which outlets were powered by the generator and their general confusion during the emergency. Interviews with various staff members, including CNAs, RNs, and the Maintenance Director, revealed a consistent lack of knowledge and training regarding emergency procedures. Staff members reported that they had not participated in any drills or received specific training on handling power outages or severe weather events. Some staff were unaware of the existence of emergency outlets, while others did not know which outlets were connected to the generator. This lack of preparedness led to difficulties in providing necessary care to residents, such as ensuring the operation of medical equipment like CPAP machines and oxygen concentrators. Residents also reported experiencing the effects of the staff's unpreparedness. Several residents mentioned that the staff appeared rattled and disorganized during the power outage and tornado warning. Some residents had to wait for staff to locate working outlets for their medical devices, and others noted that the facility's response to the emergency was chaotic. The facility's policies on disaster training and emergency procedures were not effectively implemented, resulting in a failure to ensure the safety and well-being of residents during the emergency event.
Failure to Ensure Proper Enteral Feeding Procedures
Penalty
Summary
The facility did not ensure that a resident who is fed by enteral means received the appropriate treatment and services. The resident, who has diagnoses including dysphagia, aphasia, and intellectual disability, had two different enteral feeding orders that were both being signed out as administered. The resident's enteral feeding bottle was observed without a name, date, or time it was hung for use. The facility policy requires that the enteral nutrition label be checked against the order before administration and that the date and time the formula was hung be documented on the label. However, these steps were not followed, leading to confusion and potential risk for the resident's care. During the survey, it was observed that the resident's tube feeding bottle did not have the required labeling, and the pump was set to 90 ml/hr. The RN interviewed was unable to confirm when the bottle was hung based on the label, and the DON acknowledged that there should only be one tube feeding order and that the bottle should have been labeled with the date and time. The DON also noted that the dietitian had ordered the 90 ml/hr rate in March, but the discrepancy between the two orders had not been clarified, resulting in the resident potentially receiving incorrect feeding amounts.
Failure to Obtain and Transcribe CPAP Orders Upon Admission
Penalty
Summary
The facility failed to ensure that Continuous Positive Airway Pressure (CPAP) orders were obtained and transcribed upon admission for two residents, R5 and R8, who required CPAP therapy for obstructive sleep apnea (OSA). R5 was admitted on 4/18/22 with hospital discharge orders to continue CPAP, but the order was not transcribed into her medical record until 5/24/24. Despite having a care plan indicating the need for CPAP at bedtime, the order was missing from her Medication Administration Record (MAR) until over two years later. R5 confirmed during an interview that she had been using her CPAP nightly for several years and was able to use it during emergency power situations. The Director of Nursing (DON) acknowledged that CPAP orders should have been present from admission and signed off each shift. Similarly, R8 was admitted with a diagnosis of obstructive sleep apnea but did not have CPAP orders obtained or entered upon admission. R8's care plan indicated the need for CPAP, but the orders were not documented until 5/24/24, 43 days after admission. During a power outage, R8 was sent to the emergency room due to the inability to use the CPAP effectively, and upon return, was placed on supplemental oxygen. The DON confirmed that CPAP orders should have been obtained upon admission and that any progress notes indicating oxygen orders should have been transcribed immediately. The failure to obtain and transcribe CPAP orders in a timely manner for both residents highlights a significant lapse in the facility's adherence to professional standards of practice and care planning.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and other officials, including the State Survey Agency. The incident involved a resident with moderate cognitive impairment who was verbally abused by a CNA. The abuse was reported by another CNA who overheard the incident and wrote a statement, but the facility failed to report the incident to the state as required by their policy. The resident involved had a history of hemiplegia, hemiparesis, and cognitive communication deficit following cerebrovascular disease. Despite the facility's policy requiring immediate investigation and reporting of such incidents, the Director of Nursing and the Nursing Home Administrator were unaware of the incident and did not report it to the necessary authorities. This failure to report and investigate the abuse allegation in a timely manner constitutes a deficiency in the facility's compliance with state regulations and their own policies.
Failure to Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an accusation of verbal abuse involving a resident with moderate cognitive impairment. The incident occurred when a CNA was overheard using inappropriate language towards the resident. Despite the incident being reported by another CNA, the facility did not conduct a proper investigation or report the allegation to the state agency as required by their policy. The Director of Nursing was unaware of the incident, and the Nursing Home Administrator acknowledged that such incidents should be reported and investigated. The resident involved has a history of hemiplegia, hemiparesis, and cognitive communication deficit following cerebrovascular disease. The resident's Quarterly Minimum Data Set assessment indicated moderate cognitive impairment. The failure to investigate and report the verbal abuse allegation is a clear violation of the facility's policy on abuse, neglect, and exploitation, which mandates immediate investigation and reporting of such incidents to the appropriate authorities.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that three residents received the necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Specifically, residents R3, R10, and R5 did not receive showers as scheduled. R3, who is cognitively intact and requires substantial assistance with bathing, reported not receiving showers due to staff shortages and incorrect documentation of refusals. R3's records showed multiple missed showers and bed baths over a month-long period. R10, also cognitively intact and requiring substantial assistance, similarly reported not receiving scheduled showers. R10's documentation indicated numerous missed showers and bed baths over several weeks. R10 expressed feeling unclean and gross due to the lack of proper hygiene care. Despite asking staff about his shower schedule, R10 did not receive a clear response. R5, who is dependent on staff for bathing, reported not receiving any showers since admission, except for one instance where he declined due to a family visit. R5 requested to see the shower chair before using it but never received it. The Director of Nursing confirmed that missed showers were not documented properly and that scheduled showers should have been completed and recorded. The facility's failure to provide scheduled showers and accurately document refusals led to the deficiency.
Failure to Provide Adequate Care and Monitoring
Penalty
Summary
The facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three of ten residents reviewed for quality of care. Resident 1 (R1) had a history of aspiration pneumonia and refused to comply with thickened liquid recommendations. The facility failed to care plan his refusals or assess R1 more frequently due to his increased risk of aspiration pneumonia. Despite staff observations of R1 drinking thin liquids, there was no investigation or education provided to staff on therapeutic diets and reporting dietary concerns. R1 was eventually sent to the ER with pneumonia and did not return to the facility. Resident 5 (R5) had diagnoses including morbid obesity and diabetes mellitus type two. The facility staff were not monitoring R5's bowel movements adequately. R5 experienced episodes of going several days without a bowel movement, and there was a lack of awareness among the staff regarding his bowel movement patterns. R5 also reported dietary needs that were not being met, contributing to his constipation. The facility's Director of Nursing (DON) was unaware of the specific episodes of constipation and did not have a clear protocol for monitoring bowel movements. Resident 3 (R3) did not receive wound care two times in one week for two wounds. The facility's Treatment Administration Record (TAR) showed blanks for the dates when wound care was not completed. The Treatment Nurse (TN) confirmed that if the TAR is blank, it indicates that the treatment was not done. The DON acknowledged that blanks on the TAR indicate that treatments were not documented and would need to investigate further. The facility failed to ensure that wound care was completed and documented as ordered, leading to lapses in R3's wound care treatment.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility did not ensure that the services provided by nursing personnel met the professional standards of quality for one resident. The resident was admitted with orders for Point of Care glucose testing (POCT) four times daily before meals and at bedtime. However, the facility failed to monitor the resident's blood glucose levels during their stay. This deficiency was identified through interviews, record reviews, and a review of professional standards of practice. The facility's policy on diabetes management required blood glucose monitoring upon admission and throughout the resident's stay, but this was not followed for the resident in question. The resident had a diagnosis of Type 2 Diabetes Mellitus, epilepsy, and nausea with vomiting. The hospital discharge summary included orders for POCT glucose monitoring and specific instructions to notify the Primary Care Physician if blood glucose levels were outside the specified range. Despite these orders, the resident's Medication Administration Record (MAR) for March and April did not include the POCT glucose monitoring order. The Director of Nursing confirmed that the order was not on the MAR and that the glucose levels were not being monitored as required. The failure to clarify and implement the discharge orders led to the deficiency in care for the resident.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility did not ensure the provision of pharmaceutical services to meet the needs of a resident, resulting in the resident not receiving her prescribed medications on a specific date. The resident, who has diagnoses including Type 2 Diabetes Mellitus, epilepsy, and essential hypertension, did not receive her ordered doses of amlodipine, ezetimibe, and carbamazepine. The facility's policy requires medications to be administered in a safe and timely manner, and any deviations must be documented in the Medication Administration Record (MAR) and nurse notes, which was not done in this case. The Medication Administration Record (MAR) for the resident showed that the medications were not administered, and the sign-out boxes were marked with a code indicating 'Other, See Nurse Notes.' However, there were no corresponding notes explaining why the medications were not given. Interviews with the nursing staff revealed that there is a process in place to obtain medications that are not available in the medication cart, including checking the Omnicell, calling the pharmacy, and contacting the Nurse Practitioner (NP) for alternative orders. Despite these procedures, the medications were still not administered as ordered. The Director of Nursing (DON) confirmed that it is the facility's expectation that all ordered medications are to be administered. The DON also outlined the steps to be taken if a medication is not available, which include checking the Omnicell, contacting the pharmacy, and consulting the NP. The failure to administer the medications as ordered and the lack of documentation in the nurse notes indicate a lapse in following the facility's policies and procedures for medication administration.
Supervision and Response Deficiencies in Elopement Incident
Penalty
Summary
The report details a significant deficiency in a nursing home's supervision and response to an elopement incident involving a resident identified as R5. R5, who had a complex medical history including diagnoses of cerebral infarction, dementia, muscle weakness, and mobility issues, was assessed to be at risk for elopement due to impaired safety awareness. Despite wearing a WanderGuard device and being identified as an elopement risk, R5 managed to elope from the facility on two occasions. The first elopement occurred on 12/18/23, and the second, more serious incident took place on 02/25/24, leading to the finding of Immediate Jeopardy. The facility's failure to provide adequate supervision and respond effectively to alarms during R5's elopement on 02/25/24 resulted in a situation of Immediate Jeopardy. Staff members, including a Registered Nurse and Certified Nurse Aide, did not respond promptly to the alarm triggered by R5's exit through a front door, with the alarm being reset without verifying R5's whereabouts. Subsequently, a delayed search was initiated, and law enforcement was not notified promptly, leading to R5 being found at a gas station approximately 1.5 miles away from the facility. The deficiency in supervision and response protocols, as highlighted in the report, directly contributed to the elopement incident and the subsequent Immediate Jeopardy finding. Despite R5's known elopement risk, documented in assessments and care plans, the facility's policies and procedures regarding elopement and wandering lacked specific guidance on timely notification of law enforcement and ensuring door alarms remain active until the resident is located. The report also highlighted discrepancies in staff actions and responses during the elopement incident, including delays in contacting law enforcement and inconsistencies in searching for R5 within the facility. These deficiencies in policy implementation and staff actions directly contributed to the failure to prevent R5's elopement and the subsequent Immediate Jeopardy situation.
Failure to Prevent Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse when an LPN allegedly physically grabbed a resident's arm and removed a dab/vape pen from the resident's hand. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a care plan in place to monitor for unsafe items and hold them for the resident's family to pick up. The incident occurred when the LPN, accompanied by another LPN, entered the resident's room to retrieve the dab/vape pen. The resident reported feeling violated and called the police to report the incident. Multiple staff members, including the Social Services Director and a CNA, corroborated the resident's account that the LPN had physically taken the pen from the resident's hand against their will. The Director of Nursing (DON) was initially unaware of the physical nature of the incident and did not report it to the State Agency or investigate it until later informed. The DON then suspended the LPN and initiated an investigation. The facility's policy on abuse, neglect, and exploitation, which was revised recently, mandates protections for residents' health, welfare, and rights, and prohibits such actions. Despite this policy, the incident was not reported immediately by the involved staff, and the grievance form was only filled out after the resident had already contacted the police.
Failure to Timely Report Allegation of Physical Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse to the State Agency (SA) within the required timeframe. The incident involved a resident with multiple sclerosis, bipolar disorder, and anxiety disorder, who was cognitively intact as indicated by a BIMS score of 15 out of 15. The resident alleged that an LPN physically grabbed his arm and removed a dab/vape pen from his hand. The resident did not initially report the incident to the facility but called the police instead. The facility's policy mandates that such allegations be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. However, the incident was not reported to the SA until several days later, after the Director of Nursing (DON) became fully aware of the resident's allegations. Interviews with various staff members, including the LPN involved, the Social Services Director (SSD), and a Certified Nurse Aide (CNA), confirmed the resident's account of the incident. The LPN admitted to taking the dab/vape pen from the resident's hand but claimed he did not use excessive force. The SSD and CNA corroborated the resident's story, stating that the LPN physically took the pen from the resident's closed fist. Despite being informed of the incident on the day it occurred, the DON did not report it to the SA until several days later, after realizing the resident had accused the LPN of physical abuse. This delay in reporting constitutes a failure to comply with the facility's abuse prevention and reporting policies.
Failure to Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident and an LPN. The incident involved the LPN allegedly grabbing the resident's arm and forcibly removing a dab/vape pen from the resident's hand. The resident, who has multiple sclerosis, bipolar disorder, and anxiety disorder, reported the incident to the police but did not initially inform the facility. The facility's grievance form documented the resident's complaint about the removal of the dab/vape pen, but the initial response did not include a thorough investigation into the physical abuse allegation. Interviews with the resident, the LPN involved, and other staff members revealed conflicting accounts of the incident. The LPN claimed that the resident voluntarily allowed the pen to be taken, while other staff members reported that the LPN aggressively grabbed the pen from the resident's hand. The Director of Nursing (DON) was initially unaware of the physical abuse allegation and did not investigate the incident until several days later. The facility's failure to promptly and thoroughly investigate the incident resulted in a deficiency in protecting the resident from potential abuse.
Failure to Provide CPAP Machine as Ordered
Penalty
Summary
The facility failed to ensure that a resident (R8) was using a continuous positive airway pressure (CPAP) machine as ordered by the resident's physician. The resident was admitted on an unspecified date and had a physician's order to use a CPAP machine. The resident's admission Minimum Data Set (MDS) indicated that the resident was cognitively intact with a score of 15 out of 15. An observation of the resident's room revealed that there was no CPAP machine near the bedside. The resident confirmed in an interview that she did not have a CPAP machine in her room to use at night. An LPN stated that the resident did not have a CPAP machine and that the physician was not notified of the inability to follow the physician's orders. The Director of Nursing (DON) confirmed that the resident did not have a CPAP machine available and that the physician was not notified of the facility's inability to follow the physician's orders.
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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