Muskego Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskego, Wisconsin.
- Location
- S77 W18690 Janesville Rd, Muskego, Wisconsin 53150
- CMS Provider Number
- 525686
- Inspections on file
- 28
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Muskego Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with osteomyelitis, diabetic foot ulcers, Parkinson’s disease, and moderate cognitive impairment, care planned as at risk for falls due to weakness, NWB LLE, and forgetfulness, experienced multiple falls. EMR review showed that for two of four falls, IDT fall notes documented the circumstances (rolling from bed while repositioning and being found squatting in the bathroom while attempting to get on the toilet) and that assessments, neuro checks, and VS were WNL with no injuries, but did not document whether the resident was asked about or consented to family notification, nor that family was notified. The DON confirmed that the resident was his own decision-maker, that family was notified or present for two of the falls, and that there was no documentation of the resident’s wishes or family notification for the other two falls, contrary to the facility’s “Notification of Changes” policy requiring notification of a resident representative for significant health status changes, including accidents.
The facility failed to maintain complete and accurate EMR documentation for three residents, including one with diabetic foot wounds and Parkinson’s disease, one with a brain injury and severe cognitive impairment, and one with multiple sclerosis. Missing entries included weekly skin assessments, weekly weights, meal intake percentages, and incontinent care on numerous dates, and in some cases incontinent care was recorded only once per day despite residents being always incontinent of bowel and bladder. A CNA reported that agency CNAs often did not complete documentation, and the Administrator and DON acknowledged missing documentation, contrary to the facility’s policy requiring timely and accurate charting each shift.
A resident with multiple chronic conditions reported that an LPN entered her room without knocking and attempted to administer medication while she was on the toilet, causing her distress. The incident was disclosed to a CNA and later to a social worker, but the facility did not report the abuse allegation to the state agency within the required two-hour timeframe, as confirmed by interviews and record review.
A resident with a stage 4 pressure ulcer did not receive wound care in accordance with current provider orders, as an LPN used an outdated solution and failed to perform hand hygiene at multiple required steps during a dressing change. Interviews confirmed that the care provided did not follow the most recent orders or facility policy.
A resident with multiple chronic conditions did not receive several prescribed medications, including those for blood pressure, thyroid function, pain, GERD, and potassium supplementation, on at least five occasions over two months. MARs showed missed doses, and both an LPN and the administrator confirmed these omissions as medication errors, despite facility policy requiring accurate administration and documentation.
A resident with a stage 4 pressure ulcer received wound care from an LPN who failed to wear a gown as required by the facility's Enhanced Barrier Precautions policy. The LPN performed the dressing change using only gloves, despite signage and policy indicating that both gloves and a gown were necessary for high-contact activities like wound care. The deficiency was confirmed through observation and staff interviews.
A resident filed a grievance about a CNA's conduct, and although the facility documented that the CNA would no longer be assigned to that resident, records show the CNA continued to provide care on several occasions. The scheduler was not informed of the restriction, and the CNA confirmed ongoing involvement in the resident's care, indicating a failure to follow through on the grievance resolution.
A resident with moderate cognitive impairment and significant physical limitations did not receive weekly showers as required by facility policy and their care plan. Despite being scheduled for weekly showers and expressing a preference for them, the resident received only one shower in a 30-day period, with no refusals documented. Both the NHA and DON confirmed that weekly showers should have been provided.
A resident with quadriplegia and existing heel pressure injuries did not consistently receive physician-ordered bilateral heel protectors, as documentation showed they were only applied during two specific periods and not at all other required times, according to the DON and record review.
The facility's daily nursing staff postings for the SNF were found to be inaccurate, with CBRF hours included and incorrect numbers of CNAs listed for night shifts. The postings did not match actual staff assignments, and written records of daily assignments were not maintained, leading to multiple days of inaccurate documentation.
The facility did not maintain an effective system to verify that nurses held valid licenses, allowing an LPN with a revoked license to work. Allegations of verbal abuse and misappropriation of property involving residents were not reported or investigated according to policy, with delays and omissions in notifying the NHA and State Survey Agency. These failures resulted in noncompliance with required abuse prevention and reporting procedures.
Surveyors found that the facility did not consistently implement infection prevention and control measures, including missing or improperly placed enhanced barrier precaution signage, and staff failing to use appropriate PPE and perform hand hygiene during care for residents with wounds or medical devices. Staff were sometimes unaware of which residents required EBP, and lapses in infection control practices were observed during wound care, incontinence care, and G-tube flushing.
A resident with multiple medical conditions and a legal guardian was transferred between rooms without prior written notice or consent from the resident or guardian. Staff interviews confirmed that required documentation and consent for the room changes were not completed, in violation of facility policy.
A resident with multiple complex conditions experienced significant weight loss, possible thrush, and missed prescribed tube feedings due to formula unavailability. Despite facility policy requiring prompt physician notification for such changes, there was no documentation that the physician was consulted about the weight loss or thrush, and communication gaps between the RD, nursing staff, and physician were identified.
A resident with severe cognitive impairment and total care needs was subjected to verbal abuse by a CNA, while staff failed to report previous similar incidents involving the same CNA. Despite clear signs of distress and a request for a different caregiver, the accused CNA continued to provide care, and facility leadership did not immediately recognize or act on the abuse allegation, delaying the investigation and failing to protect the resident as required by policy.
The facility did not promptly report multiple allegations of abuse and misappropriation involving three residents to the NHA and State Survey Agency as required. In one case, staff overheard a CNA verbally abusing a resident but failed to report it immediately. In another, a resident reported missing money, but the incident was not reported until days later. A third resident reported being yelled at by a nurse, but the allegation was not timely communicated to the NHA or reported to authorities. These delays violated facility policy and regulatory requirements for immediate reporting.
Three residents with varying degrees of cognitive and physical impairment experienced alleged verbal abuse by staff, but the facility failed to promptly or thoroughly investigate these allegations as required by policy. In each case, staff either did not report the incidents or delayed initiating investigations, and in one instance, the accused CNA continued working the entire shift after the allegation was known. The facility did not ensure timely protection or follow-up for the affected residents.
Two residents with complex wounds did not receive timely or appropriate wound care as ordered by physicians, including missed or delayed assessments, incomplete or improperly performed treatments, and lack of documentation. Staff failed to follow established protocols for wound assessment and treatment initiation, resulting in missed care and deviations from professional standards.
A resident with multiple pressure injuries did not receive timely and appropriate wound care as ordered by the wound physician, including delays in implementing new treatment orders, discontinuation of prescribed treatments, and failures in pressure injury prevention such as improper use of pressure-relieving devices and incorrect air mattress settings. Staff interviews revealed confusion about responsibilities for reviewing and updating wound care orders, leading to lapses in care.
A resident with a history of falls, cognitive impairment, and NPO status experienced multiple unwitnessed falls, was mistakenly given oral food despite PEG tube orders, and attempted to elope. The facility did not conduct thorough investigations, failed to identify patterns, and did not implement timely, person-centered interventions or care plan updates following these incidents.
A resident with multiple complex medical conditions experienced significant weight loss after missing several prescribed tube feedings due to unavailable formula. Staff failed to notify the physician of the weight loss, did not consistently obtain required weights, and did not update the care plan or implement new interventions in response to the resident's declining nutritional status. Recommendations from the registered dietitian and a swallow study were not fully communicated or acted upon.
A resident with end stage renal disease who receives dialysis three times a week did not have consistent pre- and post-dialysis communication between the facility and the dialysis center. Review of records showed only one incomplete dialysis communication form during a period when multiple treatments occurred, and staff interviews revealed inconsistent processes for sending and receiving these forms, with no follow-up when documentation was missing.
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. EBP signs were not consistently posted, and staff were unaware of which residents required precautions. Additionally, the infection surveillance system was inadequate, with no monthly infection rates calculated or reported to the QAPI committee. This resulted in multiple residents not receiving necessary precautions to prevent infection transmission.
The facility failed to ensure residents were free from accident hazards and received adequate supervision, as several falls were not thoroughly investigated, and care plans were not promptly updated. Additionally, a resident assessed as needing supervision while smoking did not have a smoking care plan, and smoking materials were improperly stored. The investigation process for falls was inadequate, with missing staff statements and incomplete documentation.
A resident with limited English proficiency was not provided with adequate communication resources in their primary language, Serbian, at a facility. The facility relied on family members for translation, contrary to its policy, and failed to include proper communication methods in the resident's care plan. Staff were unaware of available translation resources, leading to the resident not being fully informed about their health status and care.
The facility failed to provide written transfer/discharge notices to two residents when they were hospitalized. Despite having a policy in place, the facility did not ensure that the residents or their representatives received written notices including the date, reason, and location of transfer, as well as appeal rights and contact information for the State LTC Ombudsman. Staff interviews revealed a reliance on verbal notifications, and the DON acknowledged that written notices were not provided but would be in the future.
A resident with multiple diagnoses and at risk for pressure injuries did not receive consistent treatment for a lower back pressure ulcer, which increased in size over 14 weeks. The facility's records showed gaps in wound care, and there was no documentation of skin discolorations on the resident's heels and feet. The DON acknowledged the missing treatments and lack of documentation, focusing on larger ulcers causing pain while other areas were monitored.
A resident with hemiplegia following a stroke did not receive appropriate contracture management due to a lack of communication and documentation. The resident was observed without the prescribed splint or palm guard, and the care plan was not updated to reflect changes made by OT. Staff interviews revealed a lack of awareness about the resident's current treatment plan.
A resident admitted with a colostomy did not receive timely care consistent with professional standards. The facility failed to obtain physician orders for colostomy care until 10 weeks after admission, resulting in a lack of consistent documentation of necessary care. Interviews with staff confirmed the expectation for physician orders, which were not met, and the resident expressed concerns about the care received.
A resident requiring dialysis care did not have physician orders or a care plan in place, and assessments before and after dialysis sessions were not documented. The facility failed to ensure ongoing communication with the dialysis center, as only one partially completed communication form was provided despite multiple dialysis sessions. This lack of documentation and communication was inconsistent with professional standards of practice.
A resident requiring a sit-to-stand mechanical lift for transfers was assisted by a Resident Assistant (RA) not certified as a CNA, who performed pivot transfers instead. The RA, employed on the CBRF side, was not authorized to assist LTC residents, leading to a deficiency in staff competency and adherence to the care plan.
A resident with HIV disease missed five doses of Epoetin Alfa Injection due to the facility's failure to ensure medication availability and proper communication with the physician and pharmacy. Despite having a protocol to address such issues, the facility lacked a specific policy on missed doses, leading to the deficiency.
A facility failed to act on pharmacy medication review recommendations for a resident with multiple diagnoses, including dementia and epilepsy. The recommendations, which included medication adjustments to comply with CMS guidelines, were not reviewed or acted upon by the physician until prompted by a surveyor. The facility's process for handling pharmacy recommendations was not followed, leading to a delay in addressing the resident's medication regimen.
The facility failed to monitor adverse reactions for high-risk medications in two residents prescribed anticoagulants and diuretics. Despite facility policy, no care plans were implemented for monitoring potential side effects. The DON confirmed the absence of necessary care plans, highlighting a lapse in adherence to medication management guidelines.
A facility failed to monitor adverse effects and implement non-pharmacological interventions for a resident on psychotropic medications, and did not document an end date for another resident's PRN Lorazepam order. The first resident, with severe depression, lacked behavior monitoring, while the second resident's PRN order violated the facility's policy requiring a 14-day limit without documented rationale. These deficiencies highlight non-compliance with the facility's medication policies.
Two residents who consented to receive influenza and pneumococcal vaccines did not receive them due to lapses in the facility's immunization process. The DON acknowledged the oversight, noting the need to check vaccine stock and order from the pharmacy, but no orders were found in the medical records.
A facility failed to report an allegation of neglect involving a resident with vascular dementia and other conditions. The resident's family reported that the resident was left wet and unattended, and staff were unresponsive and rude. The Nursing Home Administrator did not report these allegations to the State Survey Agency, as required by policy.
The facility failed to thoroughly investigate a resident-to-resident altercation and an allegation of neglect. In the first case, two residents were involved in an altercation, but the investigation lacked comprehensive interviews and verification of events. In the second case, a resident's family reported neglect, but the investigation was incomplete, lacking staff statements and documentation of care. The facility's policies require thorough investigations, which were not conducted in these instances.
The facility did not ensure sufficient nursing staff by failing to designate a charge nurse for each shift, as revealed by a surveyor's review of nursing schedules and staff postings. The Director of Nursing was unaware of this oversight, which potentially affected all 39 residents.
The facility did not include the daily resident census in its nurse staff postings, as required. This was discovered during a survey when the surveyor reviewed nursing schedules and postings due to concerns about low weekend staffing. The DON acknowledged the omission and indicated plans to include the information in future postings. The NHA was informed, but no further information was provided by the facility.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds, catheters, or gastrostomy tubes, as rooms lacked necessary signage and physician orders for EBP were missing. Additionally, a CNA did not change gloves between cleaning a resident's perineal area and applying a clean incontinence brief, violating infection control practices. These deficiencies were confirmed by staff and administration, increasing the risk of cross-contamination.
The facility failed to ensure proper transcription and administration of physician orders for wound care and antibiotics. A resident with malnutrition and quadriplegia did not receive necessary dressing changes due to missing orders in the EMR. Another resident did not receive prescribed antibiotics for pneumonia due to a transcription error. The DON confirmed systemic issues in the transcription process, leading to potential harm from lack of treatment.
Failure to Document Family Notification After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to document family notification, or the resident’s wishes regarding such notification, after two of four falls experienced by one resident. The resident was admitted with osteomyelitis of the left foot, diabetic foot ulcers, and Parkinson’s disease, and had a BIMS score of 12/15, indicating moderately impaired cognition. The resident’s fall care plan, initiated due to Parkinson’s disease, weakness, non–weight-bearing status on the left lower extremity, and forgetfulness, identified the resident as being at risk for falls, accidents, and incidents. Despite this, documentation in the EMR did not reflect that the resident was asked whether he wanted his family notified following certain fall events. Review of the EMR showed that on one date the resident reported rolling from bed while repositioning, with no injuries noted, and on another date the resident was found squatting against the bathroom wall while holding onto a bar after attempting to get onto the toilet, with assessment, neuro checks, and vital signs within normal limits and no injuries noted. In both of these IDT fall notes, there was no documentation that the resident was asked if he wanted his family updated about the falls. During interview, the DON confirmed that the resident did not have a POA and was considered his own decision-maker, and that while the son was notified of one fall and the daughter was present for another, staff did not document the resident’s wishes or family notification for the other two falls. This was inconsistent with the facility’s “Notification of Changes” policy, which requires notification of the resident’s representative, if known, for significant changes in health status, including sudden illness or accident, even for mentally competent residents.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with its own documentation policy and accepted professional standards. For one resident with diabetic foot wounds, diabetes, and Parkinson’s disease, the EMR showed multiple missing weekly skin assessments over several months, despite the resident having diabetic foot ulcers and being frequently incontinent of bladder and always incontinent of bowel. Weekly weights were also missing on numerous dates from admission through discharge, and meal intake documentation lacked entries on many days, with no indication that meals were served or refused. Incontinent care documentation for this resident was also absent on several dates, and on one date was marked as not applicable due to an indwelling urinary catheter. For a second resident with a brain injury and severe cognitive impairment, the quarterly MDS indicated the resident was always incontinent of bowel and bladder and had no skin issues. However, weekly skin assessments were missing on multiple dates over a four‑month period. In the incontinent care task documentation, there were days within a 14‑day review period where no incontinent care was documented at all, and several days where incontinent care was documented only once per day. These gaps occurred despite the resident’s documented total incontinence status. For a third resident with multiple sclerosis who was cognitively intact and always incontinent of bowel and bladder, incontinent care documentation in the EMR showed numerous days with no incontinent care recorded. Additional days showed incontinent care documented only once on the 7:00 AM to 3:00 PM shift. During interviews, a CNA stated that documentation needed to be accurate but that many agency CNAs might not complete documentation, and the Administrator and DON confirmed there was missing documentation in resident records. The facility’s policy on documentation required that each medical record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation completed at the time of service or by the end of the shift in which care was provided, which was not followed in these cases.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse was reported to the state agency within the required two-hour timeframe. The incident involved a resident who reported that a night nurse entered her room while she was on the toilet and attempted to administer medication without identifying himself or knocking. The resident expressed feeling scared and shaken by the encounter, and later reported that the nurse made a comment implying he would withhold medication in the future. The resident communicated her distress to a certified nursing assistant (CNA), who consoled her but did not witness the incident. The facility's policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than two hours after the allegation is made, especially if the event involves abuse or results in serious bodily injury. In this case, the resident informed the social worker of the incident the following evening, who then relayed the information to the nursing home administrator. The administrator and director of nursing took immediate steps to suspend the nurse and begin an investigation, but the report to the state agency was not submitted until nearly 24 hours after the facility became aware of the allegation. The resident involved had a history of chronic obstructive pulmonary disease, hypertension, and hypothyroidism, and was assessed as cognitively intact. The delay in reporting was attributed to the CNA not immediately reporting the resident's disclosure of the incident, as well as the timeline of communication between staff members. The deficiency was identified based on interviews and record reviews, which confirmed that the facility did not adhere to its own policy or regulatory requirements for timely reporting of abuse allegations.
Failure to Follow Wound Care Orders and Hand Hygiene Protocols During Pressure Ulcer Treatment
Penalty
Summary
A resident with a stage 4 pressure ulcer on the left hip was admitted to the facility and had specific physician orders for wound care, including cleaning with wound cleanser, applying Hydrofera blue into the wound, and covering with bordered gauze, to be changed three times weekly and as needed. During an observed dressing change, an LPN did not follow the current physician orders and instead packed the wound with Theraform blue soaked in Dakin's solution, contrary to the updated orders which no longer required Dakin's solution. The LPN also failed to perform hand hygiene at multiple required points during the dressing change, as outlined in the facility's policy for clean dressing changes. Interviews with the LPN, the nurse practitioner, and the nursing home administrator confirmed that the wound care provided did not align with the most recent provider orders and that hand hygiene standards were not met. The nurse practitioner clarified that Dakin's solution was no longer indicated for the resident's wound, and the administrator stated that staff are expected to follow provider orders and facility policies regarding wound care and hand hygiene. These failures were identified through observation, interview, and record review.
Failure to Administer Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure the provision of pharmaceutical services to meet the needs of a resident by not administering multiple prescribed medications over several days. According to the resident's Medication Administration Records (MARs) for September and October, there were multiple instances where essential medications, including a blood pressure medication (Amlodipine), a thyroid medication (Levothyroxine), a pain medication (Gabapentin), a medication for GERD (Pantoprazole), and a potassium supplement (Potassium Chloride), were not administered as ordered. The MARs showed blanks on specific dates, indicating missed doses, which was confirmed by both an LPN and the Nursing Home Administrator during interviews. Both staff members acknowledged that blanks on the MAR meant the medications were not given, constituting medication errors. The resident involved had diagnoses including hypertension, hypothyroidism, GERD, and hypokalemia, and was cognitively intact according to a recent assessment. The resident's care plan and physician orders specified the need for these medications to manage their conditions. Facility policy required medications to be administered according to physician orders and for staff to ensure accurate documentation and administration. Despite these policies, the resident did not receive their prescribed medications on at least five days across two months, as evidenced by the MARs and staff interviews.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to implement proper infection prevention and control measures during wound care for a resident with a stage 4 pressure ulcer on the left hip. The facility's policy on Enhanced Barrier Precautions (EBP) requires the use of both gloves and a gown during high-contact resident care activities, such as wound care. During an observed dressing change, an LPN donned gloves but did not wear a gown as required by the facility's EBP policy. After completing the dressing change, the LPN removed her gloves, handled the trash bag, exited the resident's room, and disposed of the trash outside before performing hand hygiene upon reentry. The LPN acknowledged awareness of the EBP signage and policy, which specifically stated that a gown should be worn during wound care, but admitted to not wearing a gown during the procedure. The Nursing Home Administrator confirmed that staff are expected to follow the facility's infection control standards and EBP policy during wound care. The deficiency was identified through observation, interview, and record review, and involved a resident admitted with a stage 4 pressure ulcer and physician orders for regular wound care under enhanced barrier precautions.
Failure to Implement Grievance Resolution Regarding Staff Assignment
Penalty
Summary
A resident filed a grievance regarding the conduct of a Certified Nursing Assistant (CNA), specifically concerning how the CNA spoke to the resident during care. The facility investigated the grievance and documented that the CNA would no longer be assigned to care for this resident, and this information was reportedly communicated to the scheduler. However, a review of the resident's electronic health record showed that the CNA continued to provide incontinence care to the resident on multiple occasions after the grievance was filed and the resolution was documented. Interviews with facility staff revealed that the scheduler was not informed of any restrictions regarding staff assignments for this resident, and the CNA confirmed that they continued to care for the resident, sometimes with another CNA present. The Nursing Home Administrator acknowledged an oversight in the grievance resolution process, specifically in communicating the outcome to the scheduler, which resulted in the failure to implement the agreed-upon resolution to the resident's grievance.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and functional limitations in both upper and lower extremities did not receive the necessary assistance with activities of daily living, specifically with bathing. The resident's care plan and facility policy required weekly showers, and the resident's preferences included choosing between a tub bath, shower, bed bath, or sponge bath. Documentation indicated that the resident was scheduled for showers on Tuesday mornings and required the assistance of one staff member for bathing. However, review of the electronic health record showed that the resident received only one shower in the past 30 days, with no documented refusals. Interviews with the resident and a family member confirmed that the resident had not received a shower in over two weeks and had only received bed baths, despite expressing a preference for showers. Both the Nursing Home Administrator and Director of Nursing acknowledged that residents should be offered weekly showers and that there was no reason for the resident not to have received them. The facility's failure to provide the scheduled and preferred showers as outlined in the care plan and policy led to the deficiency.
Failure to Consistently Apply Ordered Heel Protectors for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident with a history of spinal cord injury, morbid obesity, quadriplegia, and a rare brain malformation was not provided with bilateral heel protectors as ordered by the physician. The resident had developed unstageable pressure injuries on both heels, and physician orders specified that heel protectors should be worn at all times, except during showers and activities of daily living, and replaced every 12 hours. Review of the Treatment Administration Record (TAR) showed that the heel protectors were only documented as being in place during two specific 12-hour periods, with no evidence of their use at other required times. The Director of Nursing confirmed that the heel protectors were not consistently applied as ordered, and documentation did not support that the resident received the prescribed pressure ulcer prevention measures. This lapse in following physician orders for pressure injury care was identified through record review and staff interview, and it affected a resident with significant risk factors for pressure injuries.
Inaccurate Daily Nursing Staff Postings for SNF
Penalty
Summary
The facility failed to ensure that the daily nursing staff posting for the skilled nursing facility (SNF) contained accurate information. The postings included hours from the community based residential facility (CBRF), and the SNF hours were either left blank or inaccurately listed the number of certified nursing assistants (CNAs) assigned during night shifts. Interviews with the receptionist responsible for the postings and the Director of Nursing (DON) revealed that the CBRF hours were routinely included on the SNF posting, and there was confusion regarding the correct number of CNAs assigned to the SNF at night. The DON stated that there are always two CNAs assigned to the SNF at night, but the postings often reflected only one or none. Further review of the facility's records showed that the daily nursing schedules and staff assignments were not maintained in written form, but instead were written on a dry erase board and erased daily, leaving no documentation of past assignments. A review of the daily nursing postings and actual staff time clock punches revealed that over a period of several weeks, there were 14 days with inaccurate nursing staff hours documented on the postings. The DON and Director of Operations acknowledged the inaccuracies and the inclusion of CBRF hours on the SNF postings.
Failure to Implement Abuse Prevention Policies and License Verification
Penalty
Summary
The facility failed to implement and enforce written policies and procedures designed to prevent abuse, neglect, exploitation, and misappropriation of resident property. Specifically, there was no effective system in place to ensure that nurses maintained a current and valid nursing license. An LPN continued to work at the facility after her license had been revoked by the Texas Board of Nursing, as the facility did not routinely verify the licensure status of agency nurses beyond the initial onboarding process. The facility's human resources and agency onboarding processes did not include ongoing checks for license validity, and the agency relied on self-reporting by the nurse for any changes in licensure status. Multiple allegations of verbal abuse and misappropriation of resident property were not reported or investigated in accordance with the facility's own policies. One resident reported verbal abuse by an LPN, but this allegation was not immediately reported to the Nursing Home Administrator or the State Survey Agency, nor was it investigated in a timely or thorough manner. In another instance, three staff members reported that a CNA was verbally abusive to a resident, but this was also not reported or investigated as required. Additionally, a resident reported missing money to a CNA, but this allegation of misappropriation was not promptly reported to the appropriate authorities. The facility's policies required immediate investigation and reporting of abuse, neglect, exploitation, and misappropriation allegations, but these procedures were not followed. Several allegations were either not reported to the required parties or not investigated in a timely and thorough manner. The lack of adherence to established policies and procedures resulted in failures to protect residents from potential abuse and exploitation, and to ensure that only properly licensed staff provided care.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple lapses in the implementation of enhanced barrier precautions (EBP) and hand hygiene protocols for four residents. Surveyors observed that required EBP signage was missing from the doors of residents who had orders or indications for EBP, including those with wounds and indwelling medical devices. In several instances, staff were unaware of which residents required EBP, and signage, when present, was not always visible to staff entering the room. Direct care staff, including LPNs, RNs, and CNAs, did not consistently wear appropriate personal protective equipment (PPE) such as gowns and gloves during high-contact care activities for residents on EBP. For example, an LPN performed wound care and G-tube flushing without donning a gown, and a CNA provided incontinence care and wound care without changing gloves or performing hand hygiene between tasks. These actions were observed despite facility policies requiring the use of gowns and gloves for EBP and proper hand hygiene before and after glove use. Interviews with the Director of Nursing, who also serves as the Infection Preventionist, confirmed expectations for hand hygiene and EBP implementation, including the need for visible signage and physician orders. However, observations revealed that these expectations were not consistently met in practice. Staff demonstrated gaps in knowledge and adherence to infection control protocols, as evidenced by their failure to perform hand hygiene at critical points and to use PPE as required by facility policy.
Failure to Provide Written Notice and Obtain Consent for Resident Room Changes
Penalty
Summary
The facility failed to provide prior written notice and obtain consent from a resident and their legal guardian before making room changes within the facility. The resident, who was cognitively intact and had a legal guardian, was transferred between rooms on at least two occasions. There was no documentation in the electronic medical record or elsewhere that the resident or their guardian received advance written notice or gave consent for these room transfers, as required by facility policy. Staff interviews confirmed that a room change form should have been completed and consent obtained, but no such documentation was found. The resident involved had multiple medical diagnoses, including cerebral infarction, hemiplegia, dysphagia, anemia, encephalopathy, bipolar disorder, anxiety disorder, and schizophrenia, and was dependent on staff for most activities of daily living. Staff interviews revealed uncertainty about the reasons for the room changes and the process followed, with some staff unaware of why the transfers occurred or whether proper procedures were followed. The facility's own policies require advance written notice and involvement of the resident and their representative in room changes, but these procedures were not followed in this case.
Failure to Notify Physician of Significant Weight Loss and Clinical Changes
Penalty
Summary
The facility failed to ensure timely physician consultation and notification regarding a resident who experienced significant weight loss, possible thrush, and issues with prescribed formula availability. The resident, who had multiple complex diagnoses including intracerebral hemorrhage, hemiplegia, chronic kidney disease, and depression, was dependent on staff for all activities of daily living and received nutrition via a gastrostomy tube. Documentation showed that the resident missed several bolus feedings due to the unavailability of the prescribed formula, and although this was eventually addressed, there was no evidence that the physician was consulted about the missed feedings or the recommendation to treat tongue thrush following a swallow study. Additionally, the registered dietitian documented significant weight loss on two separate occasions, but there was no documentation that the physician was notified or consulted regarding these changes. The facility's policy required prompt notification and consultation with the physician for significant changes in a resident's condition, but interviews and record reviews confirmed that this did not occur. Communication breakdowns between the dietitian, nursing staff, and physician contributed to the lack of timely medical intervention for the resident's significant clinical changes.
Failure to Protect Resident from Verbal Abuse Due to Delayed Reporting and Inadequate Policy Implementation
Penalty
Summary
The facility failed to protect a resident from verbal abuse by not implementing its written policies and procedures designed to prohibit and prevent abuse. A resident with severe cognitive impairment, multiple medical conditions, and total dependence on staff for care was subjected to verbal abuse by a Certified Nursing Assistant (CNA). The resident was observed crying multiple times during the morning, and when questioned, indicated through nonverbal communication that the assigned CNA was being mean and rough, and requested a different caregiver. Despite this, the CNA continued to provide care to the resident for the remainder of the shift, and the facility did not immediately initiate an investigation or remove the accused staff member from resident care duties. Further review revealed that several staff members, including two CNAs and a hospice CNA, had overheard the same CNA verbally abusing another resident weeks prior but failed to report the incident as required by facility policy. The facility's abuse prevention policy mandates immediate reporting, investigation, and protection of residents from further harm, but these steps were not followed. The accused CNA was allowed to complete the shift, increasing the risk of further abuse to other residents, and the investigation into the abuse was not started until after the CNA had left the building. Interviews with staff confirmed that the abuse allegation was not recognized or acted upon promptly by facility leadership, including the Nursing Home Administrator and Unit Manager, who did not perceive the situation as abuse when initially informed. The failure to report previous incidents and the delay in responding to the current allegation resulted in the resident being exposed to additional verbal abuse. The facility did not follow its own policies for immediate protection and investigation, nor did it ensure that staff were adequately supervised and trained to recognize and report abuse.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of abuse and misappropriation involving three residents were reported immediately to the Nursing Home Administrator (NHA) and to the State Survey Agency within the required timeframe. In the case of one resident with severe cognitive impairment and multiple medical conditions, three staff members overheard a certified nursing assistant (CNA) verbally abusing the resident, including calling the resident derogatory names. These staff members admitted they did not report the incident immediately, and the facility did not conduct a thorough investigation of the allegations at the time they occurred. Another resident, who was cognitively intact and had several chronic medical conditions, reported missing money to a CNA. The CNA documented the report, but the allegation of misappropriation was not reported to the NHA or the State Survey Agency until several days later, after the DON discovered the note in the resident's medical record. The police were eventually notified, but the delay in reporting did not meet the facility's policy or regulatory requirements for timely reporting of such incidents. A third resident, also cognitively intact, reported that a nurse had come into her room and yelled at her and her son. The resident reported the incident to a staff member transitioning to the social worker role, who then informed the DON. However, the NHA was not informed of the allegation, and the incident was not reported to the State Survey Agency within the required timeframe. The DON did not report the incident, stating that the resident did not experience ill effects. The report to the State Survey Agency was submitted after the required timeframe, and documentation of the incident was incomplete.
Failure to Timely Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal abuse involving three residents were investigated or thoroughly investigated in a timely manner, as required by their abuse prevention policy. In the case of one resident with diabetes, hypertension, and morbid obesity, the resident reported to a social worker that a nurse had screamed at her and her son during a visit. The resident stated she reported the incident to the social worker, who did not follow up, and the Nursing Home Administrator was not informed until questioned by the surveyor. The Director of Nursing did not speak directly to the resident about the allegation and did not report the incident to the state agency, citing that the resident had no ill effects. Another resident, who was severely cognitively impaired and dependent for all activities of daily living, was observed crying and indicated through nonverbal communication that a CNA was being mean and rough. The LPN and unit manager were made aware of the situation, but the CNA continued to work the entire shift before an investigation was initiated. During the investigation, it was discovered that other staff had previously overheard the same CNA verbally abusing another resident but had not reported it. The investigation into the initial allegation was not started until after the CNA had left the building, and the facility did not act immediately to protect the resident or other residents from potential further abuse. For the third resident, who had Alzheimer's disease and severe cognitive impairment, staff statements revealed that the same CNA had called the resident derogatory names on multiple occasions, but these incidents were not reported at the time they occurred. The facility did not complete a thorough or timely investigation into these allegations. The surveyor noted that the facility's failure to promptly investigate and report these allegations, as well as to protect residents from further potential abuse, was contrary to the facility's own policies and procedures.
Failure to Provide Timely and Appropriate Wound Care per Physician Orders
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, professional standards, and the residents' comprehensive care plans for two residents with complex wound care needs. For one resident with a history of end stage renal disease, peripheral vascular disease, morbid obesity, fournier gangrene, diabetes mellitus, and idiopathic aseptic necrosis of the right finger, the facility did not complete required weekly assessments of the left scrotum surgical wound and right fifth digit wound. Additionally, wound care treatments were not consistently performed as ordered by the physician. On multiple occasions, the prescribed wound care for the right fifth digit and the left scrotum was either not completed or not performed according to the specific instructions, such as using the correct dressing materials and application methods. The resident reported to the surveyor that treatments were sometimes missed, not documented, or not performed as ordered, and that he had to remind staff to complete his care. Direct observation by the surveyor confirmed that wound care was not performed according to physician orders. For example, the nurse used alternative dressing materials without a transcribed physician order and applied tape directly to the scrotum, contrary to the physician's instructions. The nurse also failed to perform the ordered treatment for the right fifth digit during the observed care session. Review of the treatment administration record (TAR) revealed missed documentation and uncompleted treatments, with staff confirming that a blank entry indicated the treatment was not done. Furthermore, there was no evidence of weekly wound assessments for the affected areas, despite facility policy and staff statements indicating that such assessments should be completed. For another resident with multiple non-pressure wounds and a history of diabetes mellitus, atrial fibrillation, heart failure, and fractures, the facility did not perform comprehensive wound assessments upon admission. The initial head-to-toe evaluation identified multiple skin alterations, but there were no detailed descriptions or measurements of the wounds, and comprehensive assessments were not completed until six days after admission by the wound physician. Additionally, daily wound treatments ordered by the physician were not initiated until two days after admission. Staff interviews confirmed that the process for wound assessment and order transcription was not consistently followed, resulting in delays in both assessment and treatment initiation.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with multiple pressure injuries received necessary treatment and services consistent with professional standards of practice. The resident, who had diagnoses including diabetes mellitus, hypertension, morbid obesity, and was assessed as being at high risk for pressure injury development, was admitted with several existing pressure injuries. The care plan included specific interventions such as administering treatments as ordered, monitoring wound healing, and using pressure relief devices. However, the facility did not consistently implement or update treatment orders as directed by the wound physician. There were significant delays and omissions in the execution of physician-ordered wound care. On several occasions, changes to wound care orders made by the wound physician were not picked up or implemented by the facility for up to eight days. For example, treatment changes for the resident's left hip, left lateral knee, and right heel pressure injuries were not acted upon until eight days after the orders were written. Additionally, the treatment for the resident's left fifth toe was discontinued by the facility despite the wound physician's order to continue, and the new order for this site was not implemented until sixteen days later. On at least one occasion, wound care for the right heel was not completed according to physician orders, as the nurse incorrectly informed the resident that the treatment had been discontinued. Observations also revealed failures in pressure injury prevention measures. The resident was seen without pressure-relieving boots and with heels resting directly on the mattress, contrary to care plan interventions for offloading. The air mattress intended for pressure relief was repeatedly set to an incorrect, firm setting, and staff were unclear about the appropriate settings. Interviews with staff indicated a lack of clarity and communication regarding responsibility for reviewing and updating wound care orders, contributing to the lapses in care.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
A resident with a history of cerebral infarction, left-sided hemiparesis, dysphagia, and multiple psychiatric diagnoses was identified as high risk for falls and accidents. Despite this, the facility failed to provide adequate supervision and implement effective interventions to prevent repeated incidents. The resident experienced three unwitnessed falls over a period of several weeks, with no documented root cause analysis or staff statements regarding the circumstances of each fall. Additionally, there was no evidence of new, person-centered interventions being added to the care plan after these incidents, nor was there documentation of a pattern, even though two falls occurred at similar times in the evening. The resident, who was NPO and received all nutrition via a PEG tube, was mistakenly provided with a regular diet and thin liquids in the dining room. There was no documented investigation into how this error occurred or which staff were involved. Interviews with staff revealed confusion about documentation practices and a lack of clarity regarding the incident. The resident's care plan and dietary orders were not followed, and the facility was unable to produce relevant incident reports or 24-hour report sheets related to the event. Following an attempted elopement, the facility did not promptly reassess the resident for elopement risk or implement appropriate interventions. The resident was not re-evaluated for elopement risk until several days after the incident, and an elopement risk care plan was not initiated until even later. There was no documented root cause analysis or staff statements regarding the circumstances of the attempted elopement, and the facility failed to correlate the resident's repeated attempts to "go home" with both the falls and the elopement attempt. These failures demonstrate a lack of thorough investigation, pattern recognition, and timely implementation of person-centered interventions as required by facility policy.
Failure to Maintain Resident Nutritional Status Due to Missed Feedings and Lack of Physician Notification
Penalty
Summary
A resident with a history of intracerebral hemorrhage, hemiplegia, chronic kidney disease, and depression experienced significant unplanned weight loss due to missed nutritional interventions. The resident, who was dependent for all activities of daily living and received nutrition via gastrostomy tube, missed a total of seven prescribed bolus tube feedings because the required formula (Nepro) was not available. Documentation shows that staff were aware of the missed feedings, but the registered dietitian was not informed, and the physician was not notified of the significant weight loss as required by facility policy. Despite the resident's weight dropping by 5.4% in one week and 6.9% over thirty days, there was no evidence that the physician was consulted or that new interventions were added to the resident's care plan in response to these changes. Weights were not consistently obtained as ordered by the physician or as recommended by the registered dietitian, with nine scheduled weights missed. Additionally, recommendations from a swallow study to treat tongue thrush were not communicated to the physician, and no corresponding treatment order was documented. The resident's care plan was not updated to reflect the ongoing nutritional issues, missed feedings, or significant weight loss. The registered dietitian communicated significant weight loss to the nursing administration, but there was a lack of follow-through in notifying the physician and updating the care plan. The facility did not conduct a root cause analysis or revise interventions in response to the resident's deteriorating nutritional status, as required by their own policies and procedures.
Failure to Ensure Consistent Pre- and Post-Dialysis Communication
Penalty
Summary
The facility failed to ensure consistent pre- and post-dialysis communication for a resident with end stage renal disease who receives dialysis three times a week. According to the facility's own hemodialysis policy, there should be ongoing communication and collaboration with the dialysis center, including completion of dialysis communication forms before and after each treatment. However, review of the resident's medical record revealed only one dialysis communication form over a period when the resident should have had multiple treatments. The single available form was incomplete, with the post-dialysis section left blank, missing critical information such as date, time, shunt status, vital signs, and general condition. Interviews with staff indicated that the process for communicating with the dialysis center was inconsistent. Nursing staff reported that sometimes the dialysis communication forms were not sent or returned, and there was no follow-up with the dialysis center when forms were missing. The Director of Nursing confirmed that no additional forms were available for review, and other staff were unclear about the communication process. This lack of consistent documentation and communication failed to meet the facility's policy requirements for monitoring and coordinating care for residents receiving dialysis.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Observations revealed that EBP signs were not consistently posted on the doors of residents who required them, and staff were not always aware of which residents were on EBP. For instance, a resident with an indwelling urinary catheter and a wound did not have an EBP sign on their door, and the staff member performing wound care did not wear the appropriate personal protective equipment (PPE), such as a gown. Additionally, the facility's infection surveillance system was inadequate. The Director of Nursing, who also served as the Infection Preventionist, did not maintain a line list of residents with symptoms of infection and did not calculate or document monthly infection rates to monitor trends. This lack of documentation and monitoring hindered the facility's ability to effectively track and respond to infections, as evidenced by the absence of infection rates for the past five months and the failure to report these rates to the Quality Assurance and Performance Improvement (QAPI) committee. The facility's failure to implement and adhere to its own policies regarding EBP and infection surveillance resulted in multiple residents not receiving the necessary precautions to prevent the transmission of infections. This included a resident with severe cognitive impairment and multiple pressure ulcers who did not have an EBP sign on their door, and staff were unaware of the need for EBP. The lack of consistent signage and staff awareness, combined with inadequate infection monitoring, contributed to the facility's inability to effectively prevent and control infections among its residents.
Deficiencies in Fall and Smoking Risk Management
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and received adequate supervision and assistance devices to prevent accidents. This deficiency was observed in several residents who experienced falls that were not thoroughly investigated, and their care plans were not promptly revised. For instance, a resident had a fall that was not investigated until several days later, and the care plan was not updated immediately to include new interventions. Another resident's fall investigation lacked staff interviews and did not document when the resident was last checked or toileted. Additionally, the facility did not adequately manage a resident's smoking habits. The resident was assessed as needing supervision while smoking, yet there was no smoking care plan in place, and the resident had access to smoking supplies in their room. The facility's policy required that smoking materials be stored by the staff, but this was not adhered to, and the resident's smoking status was not consistently documented in their care plan or CNA care card. The facility's investigation process for falls was found to be lacking, as several fall incidents did not include comprehensive statements from staff or residents, and critical sections of the fall investigation templates were left blank. In some cases, identified environmental hazards, such as poor lighting, were not addressed in the residents' care plans. The lack of thorough investigation and timely updates to care plans indicates a systemic issue in the facility's approach to managing fall risks and ensuring resident safety.
Failure to Provide Adequate Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure that a resident, whose primary language is Serbian, was fully informed of their health status and care in a language they could understand. The resident, identified as R235, was admitted with conditions including vascular dementia and type 2 diabetes. Despite being cognitively intact, the facility did not provide adequate communication methods or resources for R235, relying instead on family members for translation. This reliance on family members for communication was against the facility's policy, which states that family should not be the primary source of translation unless explicitly requested by the resident. The facility's care plan for R235 did not include interventions or resources for effective communication in Serbian. The care plan inaccurately listed a son as the translator, although no son was documented in the resident's contact list. Staff members were unaware of available resources, such as translation applications or communication boards, and instead used hand gestures or relied on the resident's family for communication. This lack of proper communication resources and training led to the resident not being fully informed about their medical condition and care. Interviews with staff revealed a lack of awareness and training regarding alternative communication methods for residents with limited English proficiency. The facility's failure to provide appropriate translation services and resources resulted in the resident's inability to effectively communicate their needs and understand their health status. The deficiency was noted by surveyors, who highlighted the inadequacy of the care plan and the inappropriate reliance on family members for translation.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices to two residents, R12 and R23, when they were hospitalized. R12, who had a healthcare Power of Attorney (POA) for medical decisions, experienced a change in condition and was transferred to the hospital. Despite requests from the surveyor, the facility could not provide evidence that a transfer notice was given to R12 or R12's POA. The Unit Manager and Licensed Practical Nurse (LPN) indicated that nurses were responsible for handling transfer notices, but there was a lack of understanding and execution of this responsibility. The Director of Nursing (DON) acknowledged that notifications were typically made via phone calls rather than in writing. R23, who had severe cognitive impairment and an activated POA, was transferred to the hospital six times over a three-month period. The facility provided bed hold notices but failed to include written information about the reasons for each transfer. The contact information for the State Long-Term Care Ombudsman and the State of Wisconsin Division of Quality Assurance was incomplete. Interviews with staff revealed a similar pattern of verbal notifications without written documentation, and the DON confirmed that written notices were not provided but would be in the future. The deficiency highlights a systemic issue within the facility regarding the failure to provide required written transfer/discharge notices, which include essential information such as the date, reason, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This oversight was consistent across multiple instances and involved both residents reviewed for hospitalizations, indicating a need for improved adherence to regulatory requirements for resident notifications.
Inconsistent Pressure Ulcer Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure injuries, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including malnutrition, osteoporosis, and vascular dementia, was at risk for pressure injuries and had existing pressure injuries that required consistent care. Despite this, the resident did not receive treatment for a lower back pressure injury on 20 out of 71 days, and there was no documentation of multiple skin discolorations over bony prominence areas where pressure injuries are likely to occur. The surveyor observed that the resident's lower back pressure ulcer increased in size over 14 weeks, from 1 x 3 x 0.1 cm to 6 x 4 x 0.5 cm. The facility's treatment administration records indicated that the resident did not receive wound care on several occasions across different months, with specific gaps noted in October, November, December, and January. Additionally, during an observation, a Licensed Practical Nurse performed wound care wearing only gloves, and multiple small, purple discolorations were noted on the resident's heels and feet, which were not documented. The Director of Nursing acknowledged the missing wound treatments and the lack of documentation regarding the skin discolorations. The resident was receiving palliative care, and the facility focused on addressing larger pressure ulcers causing the most pain, while other areas were to be monitored. However, the failure to consistently provide wound care and document skin conditions contributed to the deficiency identified by the surveyor.
Failure to Ensure Appropriate Contracture Management
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. The resident, who has hemiplegia following a stroke, was observed not wearing the prescribed splint or palm guard on multiple occasions during the survey. The resident's care plan did not include the use of a splint or palm guard as an intervention, despite a physician's order for a resting hand splint to be worn on the right hand for six hours daily. The Treatment Administration Record (TAR) showed numerous instances where staff did not document the application of the splint as ordered. Occupational Therapy (OT) notes indicated that the resident was hesitant to wear the splint and experienced skin issues, leading to a change in the contracture management plan from a splint to a palm guard. However, this change was not communicated to update the physician's order or the care plan, resulting in a lack of consistent application of the palm guard. Interviews with staff revealed a lack of awareness and communication regarding the resident's current contracture management plan. The Director of Nursing acknowledged that the change from a splint to a palm guard was not communicated effectively to the nursing staff, contributing to the deficiency in providing appropriate care to maintain or improve the resident's range of motion.
Failure to Provide Timely Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care consistent with professional standards for a resident admitted with a colostomy. The resident, who was admitted on October 25, 2024, did not have physician orders for colostomy care until January 7, 2025, approximately 10 weeks after admission. During this period, there was no consistent documentation of the necessary care and services for the resident's colostomy. The facility's policy requires that ostomy care be provided by licensed nurses under the orders of the attending physician, including specific instructions on the type of ostomy, frequency of pouch change, and type of equipment. However, these orders were not in place until well after the resident's admission. Interviews with facility staff, including a Registered Nurse, a Licensed Practical Nurse, and the Director of Nursing, revealed that there was an expectation for a physician order for colostomy care, which was not met in this case. The resident expressed concerns about the colostomy care received, indicating that care was lacking at the beginning of their admission. The facility's documentation showed only one instance of colostomy care being provided on November 12, 2024, with no further documentation until after the physician order was placed in January. This lack of timely and consistent care documentation highlights a deficiency in adhering to the facility's policy and professional standards of practice for colostomy care.
Failure to Provide Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for a resident, identified as R485, who required such services. Upon admission, R485, who had a history of end-stage renal disease and other significant health conditions, did not have physician orders for hemodialysis or a care plan in place for monitoring and managing dialysis-related complications. The facility's policy required ongoing evaluation and communication with the dialysis center, but these were not documented in R485's electronic medical record. The surveyor found that there was no evidence of assessments being completed before or after dialysis sessions for R485. Additionally, there was a lack of documentation regarding communication between the facility and the dialysis center. Only one partially completed dialysis communication form was provided, despite R485 having undergone multiple dialysis sessions. The facility's Director of Nursing acknowledged the absence of a care plan and physician orders specific to R485's dialysis needs. The surveyor noted that the facility's failure to ensure proper documentation and communication regarding R485's dialysis care was inconsistent with professional standards of practice. This deficiency was highlighted by the absence of physician orders, care plans, and completed assessments, which are necessary to monitor the resident's condition and prevent complications associated with dialysis treatment.
Inappropriate Transfer Assistance by Unqualified Staff
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets necessary to care for a resident's needs, specifically affecting one resident (R29) out of twelve reviewed. R29, who has multiple sclerosis, generalized anxiety disorder, and recurrent depressive disorder, was assessed to require a sit-to-stand mechanical lift for transfers. However, it was observed that a Resident Assistant (RA-T), who is not a certified nursing assistant (CNA) and works in the community-based residential facility (CBRF) side of the facility, was assisting R29 with pivot transfers into a wheelchair to go outside for smoking. This assistance was contrary to the care plan, which specified the need for a mechanical lift for transfers. The surveyor's review of the facility's staffing list and RA job description revealed that RA-T was not employed to assist residents on the long-term care side of the building and was not certified to provide such care. The Director of Nursing (DON) confirmed that RA-T should not assist residents alone and that the RA job description did not include assisting CNAs with long-term care residents. The deficiency was identified when the surveyor observed and interviewed R29, who confirmed the assistance provided by RA-T, which was not in line with the resident's assessed needs and care plan.
Failure to Administer Medication Safely and Accurately
Penalty
Summary
The facility failed to ensure the accurate and safe administration of medication for a resident diagnosed with human immunodeficiency virus (HIV) disease, resulting in five missed doses of Epoetin Alfa Injection Solution. The resident, who was cognitively intact and suffering from severe depression, had a physician's order for the medication to be administered subcutaneously at bedtime every Tuesday, Thursday, and Saturday for anemia related to HIV disease. However, the medication was not available after the resident's admission, leading to missed doses on five separate occasions. The surveyor's findings revealed that there was no documentation indicating that the physician or pharmacy was contacted regarding the unavailability of the medication. Interviews with the registered nurse and the Director of Nursing confirmed that the medication was pending delivery and that the protocol for such situations involved notifying the physician and contacting the pharmacy. However, there was no policy in place addressing missed medication doses, and the facility failed to follow the protocol, resulting in the deficiency.
Failure to Act on Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to act upon pharmacy medication regimen review reports for a resident, identified as R21, who was admitted with diagnoses including dementia, traumatic brain injury, epilepsy, anxiety, and depression, and was receiving hospice services. The pharmacy reviews for R21, dated 9/10/2024 and 11/11/2024, included recommendations for medication adjustments that were not acted upon by the attending physician until prompted by the surveyor. These recommendations included adding a stop date for PRN Ativan, adjusting the dosing schedule for zonisamide and topiramate to reduce medication pass burden, and ensuring compliance with CMS guidelines for PRN psychotropic medications. The surveyor's review revealed that the facility's process for handling pharmacy recommendations was not followed, as the recommendations were not reviewed or acted upon in a timely manner. The Director of Nursing (DON) acknowledged the process involves receiving recommendations via email, which are then given to the physician for review and order changes. However, the DON was unsure why R21's recommendations were not addressed until the surveyor's intervention. The physician only signed the recommendations and issued new orders on 1/27/2025, after the surveyor requested documentation, indicating a lapse in the facility's medication review process.
Failure to Monitor High-Risk Medications
Penalty
Summary
The facility failed to ensure proper monitoring for adverse reactions of high-risk medications for two residents, R31 and R485, who were prescribed anticoagulants and diuretics. R31, who was admitted with conditions including chronic embolism, thrombosis, and hypertension, was prescribed Eliquis and Furosemide. However, the facility did not implement a care plan to monitor for potential adverse side effects from these medications. During an interview, the Director of Nursing (DON) acknowledged the absence of a care plan for R31, which was contrary to the facility's policy on managing high-risk medications. Similarly, R485, who was admitted with end-stage renal disease and other chronic conditions, was prescribed Apixaban and Furosemide. The facility also failed to create a person-centered care plan to monitor for adverse effects of these medications. The DON confirmed the lack of a care plan for R485 during an interview, admitting that both residents should have had care plans in place according to the facility's policy. This oversight indicates a failure to adhere to the established guidelines for managing high-risk medications, potentially compromising resident safety.
Deficiencies in Psychotropic Medication Monitoring and PRN Order Compliance
Penalty
Summary
The facility failed to ensure proper monitoring and implementation of non-pharmacological interventions for a resident receiving psychotropic medications. The resident, identified as R485, was prescribed Mirtazapine and Seroquel for depression and mood disorder but did not have orders for monitoring adverse effects or non-pharmacological interventions. Despite the resident's severe depression and complaints of not being listened to, there was no documentation of behavior monitoring or effectiveness of the medications. The staff acknowledged the lack of monitoring and stated that the resident often ignored them, complicating efforts to address the resident's mental health needs. Another deficiency was identified concerning the administration of PRN psychotropic medication for a resident, R21, who was prescribed Lorazepam for anxiety, restlessness, agitation, and seizures. The medication order did not include an end date, which is against the facility's policy that requires PRN orders to be limited to 14 days unless a rationale and duration are documented. The oversight was acknowledged by the Director of Nursing and the Nursing Home Administrator during the surveyor's review. The facility's policy on the use of psychotropic medications emphasizes the necessity of monitoring and documentation of the resident's response to medications, as well as the implementation of non-pharmacological interventions. However, the facility failed to adhere to these guidelines for the residents reviewed, leading to deficiencies in the care provided. The lack of monitoring and documentation for both residents highlights a significant gap in the facility's compliance with its own policies and regulatory requirements.
Failure to Administer Consented Vaccinations
Penalty
Summary
The facility failed to ensure that residents received the influenza and pneumococcal immunizations as per their consent, resulting in a deficiency. Specifically, two residents, identified as R37 and R23, consented to receive the influenza and pneumococcal vaccines, respectively, but did not receive them. The facility's policy, dated May 16, 2023, mandates that residents be offered these vaccines unless contraindicated or already received elsewhere, and that documentation should reflect the education provided and the administration of the vaccines. During interviews conducted on January 23, 2025, the Director of Nursing (DON), who also serves as the facility's Infection Preventionist, acknowledged that R37 had not received the influenza vaccine and R23 had not received the pneumococcal vaccine. The DON indicated that they believed the influenza vaccine was in stock for R37 and that the pneumococcal vaccine needed to be ordered for R23. However, there were no orders for the administration of these vaccines in the residents' medical records, highlighting a lapse in the facility's adherence to its immunization policy.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident, identified as R235, to the State Survey Agency. The incident occurred during the night shift on January 8, 2025, when R235's family member reported that the resident was left wet and unattended for several hours. Despite the family member's attempts to contact the facility, the phone was reportedly not answered, prompting the family member to visit the facility in person. Additionally, the family member reported that staff were rude and dismissive during interactions. The Nursing Home Administrator (NHA) did not report these allegations to the State Survey Agency as required by the facility's policy. R235, who was admitted to the facility with diagnoses including vascular dementia, type 2 diabetes, and bradycardia, was assessed as needing extensive assistance with personal care tasks. The resident's family member had previously reported similar concerns about neglect and staff behavior on January 3 and 4, 2025. When questioned by the surveyor, the NHA stated that staff claimed the family member was rude and that rounds were being completed every two hours. However, the NHA did not verify whether the facility phone was operational or if rounds were conducted as reported. This lack of verification and failure to report the neglect allegations constituted a deficiency in the facility's compliance with its abuse prevention policy.
Inadequate Investigation of Resident Incidents
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident altercation involving two residents, R7 and R30, which was reported to the State Survey Agency. The incident occurred when R7 entered the room to use the restroom and R30's hand connected with R7's shoulder. The facility's documentation of the incident was inconsistent with R7's account, who reported that R30 hit him with a fist. The investigation lacked comprehensive interviews with other staff or residents who might have witnessed the incident, and there was no verification of the events as described by the involved parties. Additionally, the facility did not adequately investigate an allegation of neglect reported by R235's family member. The family member reported that R235 was left wet and unattended during the night, and staff were unresponsive to phone calls. The investigation did not include statements from all relevant staff, and there was no documentation verifying that regular rounds were conducted as claimed. The facility also failed to recognize these concerns as potential neglect, and there was no evidence that the phone system was checked for missed calls. The facility's policies on abuse, neglect, and exploitation require immediate and thorough investigations of such allegations, including interviews with all involved parties and complete documentation. However, in both cases, the investigations were incomplete, lacking necessary interviews and documentation to substantiate the claims or to ensure that appropriate measures were taken to prevent recurrence.
Failure to Designate Charge Nurse for Each Shift
Penalty
Summary
The facility failed to ensure that sufficient nursing staff was provided to meet the needs of all residents, as evidenced by the lack of a designated charge nurse for each shift. This deficiency was identified through observation, interviews, and record reviews conducted by the surveyor. The surveyor requested nursing schedules and staff postings for a specific period due to concerns about low weekend staffing reported in the Payroll Based Journal. Upon review, it was noted that the facility's nursing schedules did not specify who the charge nurse was for each tour of duty. During an interview, the Director of Nursing (DON) acknowledged responsibility for coordinating the nursing schedule and preparing staff postings. However, the DON admitted to being unaware that the schedules lacked a designated charge nurse for the specified period. The Nursing Home Administrator was informed of this issue, but the facility did not provide any additional information or justification for the oversight. This deficiency potentially affected all 39 residents residing in the facility.
Omission of Daily Census in Nurse Staff Postings
Penalty
Summary
The facility failed to ensure that the daily nurse staff postings included all required information, specifically the daily resident census. This deficiency was identified during a survey when the surveyor requested nursing schedules and nurse staff postings for a specific period due to concerns about low weekend staffing reported in the Payroll Based Journal. Upon review, it was noted that the facility's postings did not include the daily census number for the specified periods. During an interview, the Director of Nursing (DON) acknowledged the omission and stated that they would add the daily census information to future postings. The Nursing Home Administrator was also informed of the concern, but no additional information was provided by the facility at that time.
Failure to Implement Enhanced Barrier Precautions and Proper Infection Control
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for five residents who required such measures due to the presence of wounds, indwelling urinary catheters, or gastrostomy tubes. Observations revealed that rooms lacked signage indicating the type of personal protective equipment (PPE) required for direct care, and physician orders for EBP were absent for these residents. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that EBP were not being applied, and staff were not using PPE when providing care to residents with catheters, wounds, or gastrostomy tubes. Additionally, the facility failed to adhere to proper infection control practices during incontinence care for one resident. A Certified Nursing Assistant (CNA) was observed not changing gloves between cleaning the resident's perineal area and applying a clean incontinence brief. This practice was confirmed by the CNA and the DON, who acknowledged that the expectation was to change gloves after removing a soiled brief before applying a clean one. The deficiency in infection prevention and control practices was further corroborated by the facility's administration, who confirmed the absence of necessary signage and the failure to follow proper infection control protocols. These lapses in protocol increased the potential for cross-contamination and transmission of multidrug-resistant organisms among residents.
Deficiencies in Transcription and Administration of Physician Orders
Penalty
Summary
The facility failed to ensure professional standards of care were met in the transcription and administration of physician orders for wound care and antibiotics. For one resident, the wound care physician's orders for treating skin wounds were not properly reviewed or documented in the electronic medical record (EMR), leading to a lack of necessary dressing changes. The resident, who was admitted with conditions including moderate protein-calorie malnutrition and quadriplegia, had documented skin alterations that were not adequately described or addressed in nursing assessments. The Director of Nursing (DON) confirmed that the orders were missing from the EMR, resulting in the omission of wound treatments. Another resident experienced a failure in the transcription of antibiotic orders following a hospital readmission. The resident, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was prescribed antibiotics for aspiration pneumonia. However, the medication was not transcribed into the resident's chart, and the resident did not receive the prescribed antibiotics. The DON confirmed that a transcription error occurred, and the medication order was not completed in the Point Click Care (PCC) system. Interviews with the DON revealed systemic issues in the transcription process for both wound care and medication orders. The DON acknowledged a break in the system for transcribing orders from the wound care provider to the EMR, as well as a failure to complete the antibiotic order in the PCC system. These deficiencies resulted in the potential for decreased healing and harm due to the lack of treatment and administration of necessary medications.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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