Monroe Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Wisconsin.
- Location
- 516 26th Ave, Monroe, Wisconsin 53566
- CMS Provider Number
- 525292
- Inspections on file
- 22
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Monroe Health Services during CMS and state inspections, most recent first.
A resident's cell phone was misappropriated by a housekeeper, who was later terminated based on evidence, although the theft could not be conclusively proven. The resident, who was cognitively intact, reported seeing the housekeeper take the phone. The facility's policy on abuse prevention was not effectively implemented, and the contracted housekeeping company failed to provide adequate follow-up training to its staff.
A resident with Chronic Kidney Disease Stage 4 had critical lab results that were not communicated to a provider. The facility's process for handling lab results broke down, as the Nurse Practitioner was on vacation and the on-call provider was not notified. Staff interviews revealed no specific timeframe for checking lab results, and the Director of Nursing expected follow-up that did not occur.
A resident with a history of osteoporosis was found with a bruise on her arm, which was not reported to the State Agency within the required timeframe. The facility's policy requires immediate reporting of such incidents, but the Nursing Home Administrator and Director of Nursing delayed reporting until the resident's family alleged abuse. An x-ray later revealed a fracture, highlighting a deficiency in the facility's reporting procedures.
A facility failed to create a comprehensive care plan for a resident prescribed Melatonin for insomnia. The care plan did not include the medication, and there was no sleep assessment or tracking to evaluate its effectiveness. Interviews with facility staff confirmed the absence of necessary assessments and monitoring.
A resident with essential hypertension had physician orders for daily weights over seven days, but the facility failed to document weights on three days. Despite this, the MAR was signed for all days, indicating a discrepancy. Interviews with staff confirmed that weights should be documented in the PCC system daily, but this was not done, leading to a failure in following physician orders.
The facility failed to provide adequate wound care and post-fall assessments for residents. Two residents did not receive documented wound care as per orders, and a resident who fell was moved without a complete RN assessment, leading to a missed fracture diagnosis.
A resident with a stage 3 pressure wound on the left calf did not receive prescribed treatment due to a failure to transcribe the wound care order onto the Treatment Administration Record (TAR). The treatment, which included the application of Leptospermum honey and a secondary dressing, was not completed on multiple days. The Director of Nursing confirmed the lapse in documentation and treatment, acknowledging that if it was not documented, it was not done. Despite this, the resident's wound did not worsen during the period of non-compliance.
Two residents experienced medication administration errors, resulting in a 5.88% error rate. An RN failed to assess vital signs before administering Lisinopril, and an LPN gave Omeprazole with breakfast instead of one hour prior, both against physician orders.
A resident with severe cognitive impairment and multiple falls had inaccurate fall risk assessments in their medical records. Despite being on medications that increased fall risk, assessments often indicated a low risk. Interviews with staff revealed inconsistencies in the assessment process, and the DON acknowledged the inaccuracies.
A resident was given an antibiotic for a suspected UTI before urine culture results were finalized. The culture showed mixed flora with no specific bacteria, yet the antibiotic treatment continued without consulting the physician or recollecting a sample. The ADON/IP relied on the CFU/ml result, and the DON expected physician consultation, highlighting a failure in the facility's antibiotic stewardship program.
Misappropriation of Resident's Property by Housekeeper
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically a cell phone, by a housekeeper. The incident involved a resident who was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. The resident reported seeing a housekeeper take her phone and put it in her pocket. The phone was later found in the car of another housekeeper, with whom the accused housekeeper was carpooling. Despite the resident's clear account of the event, the facility and police were unable to substantiate the theft, but the housekeeper was terminated based on the evidence. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent the misappropriation of the resident's property. The facility's response included suspending the housekeeper and involving the police, but the investigation did not conclusively prove the theft. Interviews with staff and the resident confirmed the resident's account, but the facility's contracted housekeeping company did not provide adequate follow-up training or reeducation on abuse prevention to its staff. The incident highlighted a gap in the facility's oversight of contracted staff, as the housekeeping company was responsible for background checks and training. The facility's administration and nursing staff were involved in the investigation, but there was a lack of coordination with the contracted housekeeping company to ensure all staff received necessary abuse prevention training. This deficiency in communication and training contributed to the failure to protect the resident's property effectively.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a need to alter treatment, as evidenced by the lack of notification regarding abnormal lab results for a resident. The resident, who was admitted with multiple diagnoses including Chronic Kidney Disease Stage 4, had lab results showing significantly elevated Blood Urea Nitrogen (BUN) and Creatinine levels, and a low Glomerular Filtration Rate (GFR). Despite these critical findings, there was no evidence that the lab results were communicated to or reviewed by a provider. Interviews with facility staff revealed a breakdown in the process of handling lab results. The Nurse Practitioner who ordered the labs was on vacation, and the facility did not notify the on-call provider of the results. The Director of Nursing and Unit Manager indicated that there was no specific timeframe for checking lab results, and the Unit Manager did not recall the resident's labs. The Director of Nursing expected staff to follow up with the provider once lab results were received, but this did not occur, leading to a failure in addressing the resident's critical condition in a timely manner.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime in accordance with section 1150B of the Act, specifically regarding an injury of unknown origin for a resident, identified as R10. R10, who has a medical history including Alzheimer's disease, osteoporosis, dementia, generalized anxiety disorder, and major depressive disorder, was found with a bruise on her upper right arm on 7/7/24. Despite the facility's policy requiring immediate reporting of such incidents, the injury was not reported to the State Agency until 7/11/24, which is beyond the required timeframe. The facility's policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported immediately, but not later than 24 hours if the events do not involve abuse or result in serious bodily injury. However, the Nursing Home Administrator (NHA) and Director of Nursing (DON) did not adhere to this policy. The NHA reported the incident only after R10's family alleged abuse, despite being aware of the injury on 7/7/24. The DON initially assessed the bruise as small and not of unknown origin, attributing it to changing R10's clothing, but later acknowledged the bruise had grown significantly by 7/8/24. The delay in reporting was further compounded by the facility's decision to pursue an x-ray only after the family insisted, which revealed a fracture with displacement of the humeral head. The NHA and DON both acknowledged the reporting delay, with the DON stating that the injury should have been reported immediately, especially when physical harm is alleged. The facility's failure to report the injury within the required timeframe constitutes a deficiency in their reporting procedures.
Failure to Develop Comprehensive Care Plan for Resident on Melatonin
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R35, who was prescribed Melatonin for insomnia. Despite the resident's cognitive intactness and existing diagnoses of weakness, obstructive sleep apnea, and depression, the care plan did not include any mention of Melatonin use. The facility's policy mandates that care plans should include measurable objectives and timeframes to meet the resident's needs, but this was not adhered to in R35's case. The care plan, dated February 2024, only mentioned sleep cycle issues related to depression without addressing the Melatonin prescription. Additionally, there was no sleep assessment or sleep tracking documented for R35, which is crucial to evaluate the effectiveness of the Melatonin treatment. The Medication Administration Record from May to July 2024 lacked any documentation of sleep tracking or the effectiveness of the medication. Interviews with the Vice President of Success and the Director of Nursing revealed that the facility did not conduct a sleep assessment for R35, and the Director of Nursing acknowledged the necessity of sleep monitoring for residents on sleep medication.
Failure to Document Daily Weights as Ordered
Penalty
Summary
The facility failed to meet professional standards of quality by not adhering to physician orders for daily weight monitoring of a resident, identified as R40, who was admitted with essential hypertension. The physician had ordered daily weights for seven days, but the facility did not complete this task on three of those days. Despite the absence of weight documentation for these days, the Medication Administration Record (MAR) was signed for all seven days, indicating a discrepancy between recorded actions and actual practice. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), revealed that weights should be documented in the Point Click Care (PCC) system on the same day they are taken. The DON confirmed that the facility's policy requires weights to be documented in PCC to ensure that any significant weight changes are communicated to the physician. However, the lack of documentation for three days meant that the facility did not follow the physician's orders, and staff would not have been aware of any necessary updates to the physician regarding weight changes.
Deficiencies in Wound Care and Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. For two residents with non-pressure wounds, there were multiple instances where wound care treatments were not documented as completed on the Treatment Administration Record (TAR). One resident, who was cognitively intact, had specific orders from a wound doctor that were not transcribed onto the TAR or completed, leading to gaps in wound care. Another resident had similar issues with wound care treatments not being documented, indicating they were not completed as per the orders. Additionally, the facility did not conduct a thorough assessment following a fall for a resident who later was found to have a fracture. The resident, who had a history of hemiplegia and osteoporosis, fell while reaching for a cupcake. The resident was moved from the floor to a wheelchair and later to a bed without a complete assessment by a Registered Nurse (RN). The documentation provided was inconsistent and lacked a full physical assessment, which is required after a fall. Interviews with facility staff, including the Director of Nursing (DON) and the Infection Preventionist/Wound Nurse, revealed that there were lapses in the process of entering and completing wound care orders. The DON confirmed that if treatments are not documented, they are considered not done. Furthermore, the RN involved in the post-fall incident admitted to not completing a full assessment and moving the resident without proper evaluation, which is against the facility's policy for fall management.
Failure to Administer Pressure Ulcer Treatment as Ordered
Penalty
Summary
The facility failed to implement professional standards of practice for pressure ulcer care for a resident, identified as R147, who was reviewed for pressure injuries. The resident, who was admitted with a stage 3 pressure wound on the left calf, had a treatment plan prescribed by a wound doctor, which included the application of Leptospermum honey and a secondary dressing of gauze island with a border, to be applied once daily for 23 days. However, this order was not transcribed onto the resident's Treatment Administration Record (TAR) and was not completed as ordered on multiple days. The facility's policy requires that new medication orders be documented in the resident's medical record and entered into the TAR. Despite this, the treatment for R147's pressure injury was not documented or completed from 5/21/24 to 6/6/24. The Director of Nursing (DON) confirmed that the orders were not on the TAR during this period and acknowledged that if it was not documented, it was not done. Although the resident's wound did not worsen during the time the treatment was not completed, the facility did not adhere to its policy of administering treatments as ordered and monitoring for effectiveness.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 5.88%, exceeding the acceptable threshold of 5%. This was based on two errors observed during a medication pass task involving two residents. The first error involved a registered nurse (RN) who administered Lisinopril to a resident without assessing the resident's vital signs, as required by the physician's orders. The orders specified that the medication should be held if the resident's systolic blood pressure was below 100, diastolic blood pressure was below 60, or heart rate was below 60. The RN admitted to not taking the vital signs on the day of the observation, despite being aware of the hold parameters. The second error involved a licensed practical nurse (LPN) who administered Omeprazole to another resident with breakfast, contrary to the physician's orders that specified the medication should be given one hour before breakfast. The LPN acknowledged the error during an interview with the surveyor. The Director of Nursing confirmed that medications should be administered as ordered and recognized both instances as medication errors. The facility's policy on medication administration was not adhered to in these cases, leading to the identified deficiencies.
Inaccurate Fall Risk Assessments for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident identified as R39, who was at high risk for falls. R39's medical records contained inaccurate fall risk assessments following five falls within the facility over a three-month period. The resident was admitted with diagnoses including encephalopathy, vascular dementia, and polyneuropathy, and was severely cognitively impaired with a BIMS score of 3 out of 15. Despite these conditions and a history of falls, the fall risk assessments inaccurately reflected the resident's fall risk level, often indicating a low risk when the resident had multiple falls and was on medications that increased fall risk. The post-fall assessments for R39 were inconsistent and did not accurately document the number of falls or the medications that contributed to the fall risk. For instance, one assessment indicated no falls in the past 30 days and 1-2 falls in the past 90 days, when the resident had actually experienced three falls. Additionally, the assessments failed to account for medications such as a diuretic, laxative, psychotropic medication, and antidepressant, which were known to increase fall risk. This lack of accurate documentation and assessment led to an underestimation of the resident's fall risk. Interviews with facility staff, including an LPN, RN, and the DON, revealed a lack of consistency in the fall risk assessment process. Staff acknowledged that recent falls and certain medications should increase a resident's fall risk, yet the assessments did not reflect this understanding. The DON admitted that the fall risk assessments for R39 were not accurate and should have been completed correctly. This deficiency in maintaining accurate medical records and assessments compromised the facility's ability to effectively manage and mitigate the resident's fall risk.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program, which is part of its infection prevention and control program, by not following antibiotic use protocols and failing to monitor antibiotic use effectively. A resident, identified as R2, was administered an antibiotic, cefuroxime, for a suspected urinary tract infection (UTI) before the urine culture results were finalized. The urine culture results, which were available the day after the antibiotic was started, indicated mixed flora with no specific bacteria isolated, and suggested recollection if clinically indicated. Despite this, the antibiotic treatment continued without further consultation with the physician or recollection of a urine sample. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) and the Director of Nursing (DON) were interviewed and acknowledged the oversight. The ADON/IP admitted to relying solely on the >100,000 CFU/ml result for treatment, while the DON expressed that the expectation would have been to contact the physician to discuss the results and consider recollecting a urine sample. The facility's failure to reassess the need for antibiotics after receiving the culture results, which did not confirm a specific infection, led to the continuation of unnecessary antibiotic treatment for R2.
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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