New Glarus Home
Inspection history, citations, penalties and survey trends for this long-term care facility in New Glarus, Wisconsin.
- Location
- 600 2nd Ave, New Glarus, Wisconsin 53574
- CMS Provider Number
- 525630
- Inspections on file
- 24
- Latest survey
- February 16, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at New Glarus Home during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a documented history of sexually inappropriate behavior toward other male residents had his supervision progressively reduced and ultimately discontinued despite prior incidents of non-consensual genital touching. Later, this resident was found in another cognitively intact resident’s room with his hand inside the other resident’s pants, touching his penis and upper thigh; the second resident reported the contact was not consensual. Staff interviews and records confirmed that the abusive resident was known to be sexually inappropriate, and that facility policies required prevention of abuse and monitoring of residents with behaviors that might lead to conflict, but supervision was not consistently maintained, leading to an Immediate Jeopardy finding related to failure to protect residents from sexual abuse.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident due to the facility's failure to implement and communicate care plan interventions, such as 1:1 supervision and motion sensor alarms. Staff were unaware of the required interventions, and documentation and education regarding the incident were incomplete, resulting in inadequate protection for the resident.
Two CNAs did not receive required annual performance evaluations, as confirmed by record review and interview with the DON, who stated that yearly evaluations are expected for all CNAs.
A registered nurse did not perform required hand hygiene after removing gloves at multiple points during wound care for a resident with a left knee wound. Despite facility policies mandating handwashing after glove removal, the nurse continued the procedure without proper hand hygiene, a lapse confirmed by both the nurse and the DON during interviews.
The facility experienced a COVID-19 outbreak affecting 38 residents and 18 staff members due to inadequate infection control measures. Staff were observed improperly doffing PPE in hallways, contaminating clean PPE, and not adhering to hand hygiene protocols. The facility failed to document COVID-positive residents' symptoms and did not fit test agency staff for N95 masks. The infection preventionist was not adequately trained, and testing for symptomatic residents was delayed.
Two residents' rights to receive visitors of their choosing were violated when the facility restricted visits based on the wishes of their POAs, who only had authority over health care decisions. Despite one resident being cognitively intact and the other having moderate cognitive impairment, the facility acted on the POAs' requests without legal authority, leading to a deficiency in honoring residents' visitation rights.
A resident with severe cognitive impairment was found in another resident's room, engaging in inappropriate contact. The facility failed to implement new interventions or update care plans to prevent recurrence. The incident was not reported to the state agency within the required timeframe, and not all staff received abuse training.
A facility failed to report an alleged abuse incident within the required 2-hour timeframe. A CNA found a resident sitting on another resident's bed, with the latter's brief pulled down and being touched inappropriately. The incident was discovered at 4:30 AM, but the report to the State Agency was delayed until 10:39 AM. Both residents were non-interviewable, and the facility initially viewed the incident as a resident-to-resident altercation, contributing to the reporting delay.
A facility failed to investigate and prevent a resident-to-resident abuse incident where one resident was found fondling another. The facility did not update care plans or implement increased supervision, and no abuse education was provided to staff. Interviews with the DON and NHA revealed no specific interventions were put in place to ensure resident safety.
A resident at high risk for pressure injuries developed a Stage 3 pressure injury due to the facility's failure to implement preventive measures and timely interventions. Despite being aware of the resident's high risk status, the facility did not have skin interventions in place, and there were delays in notifying the physician and applying appropriate wound care. Observations revealed inconsistencies in dressing management, particularly during shifts with agency staff.
A resident experienced severe weight loss due to the facility's failure to monitor her nutritional status and implement appropriate interventions. Despite being at risk, the resident's care plan was not updated, and her weight was not consistently monitored. The registered dietician's recommendations were not followed up on, and the resident's cognitive decline was not addressed, leading to continued nutritional decline.
The facility's QAA Committee did not include the required members, specifically the DON and IP, during QAPI meetings in February and June 2024. The facility's QAPI plan failed to list the IP as a member, contrary to policy. The NHA confirmed the absence of these members, affecting the facility's compliance with regulatory requirements.
The facility failed to maintain an effective Infection Control Program, lacking a water management team and proper documentation. Clean linens were transported uncovered, and staff lacked appropriate PPE. A resident with infection symptoms was not added to the line list, indicating poor communication and documentation practices.
The facility did not consistently offer bedtime snacks to residents when there was a 15-hour gap between dinner and breakfast, affecting all residents. Staff confirmed that snacks were not routinely provided, and the facility's policy requiring bedtime snacks was not followed. Meals were also served late, contributing to the issue.
The facility failed to maintain a sanitary environment in its kitchen, affecting all residents. Staff were observed without hair restraints, wet dishes were improperly stacked, dented cans were in circulation, and opened food items were not labeled or dated. Additionally, kitchen equipment was found unclean, violating facility policies.
The facility did not have enough trained staff in the food service department, leading to delayed meal services for residents. Meals were consistently served late, with breakfast and lunch delayed by up to 55 minutes. Residents, including those with complex medical conditions, expressed concerns about the timeliness of their meals. The facility's meal schedule was not followed, and there was no system to track actual delivery times, contributing to the issue.
The facility failed to follow its policy regarding the Resident Council, resulting in delayed responses to grievances and unauthorized staff presence at meetings. Residents reported not receiving timely follow-ups on their concerns, and the previous administrator attended meetings uninvited. Issues such as delayed call light responses and inconsistent medication times were documented but not addressed promptly, contributing to resident dissatisfaction.
Two residents reported cold showers, with water temperatures confirmed to be below comfortable levels. The Maintenance Director was unaware of the process for checking water temperatures, and no records of temperature checks were found. The Nursing Home Administrator expected maintenance staff to be knowledgeable about appropriate water temperatures and the facility's policy, but this was not the case.
The facility failed to ensure a safe environment by improperly charging motorized wheelchair batteries outside of fire-safe areas and inadequately supervising a resident transfer without a gait belt. The DON was unaware of the charging practices, and an LPN confirmed the need for a gait belt during the resident's transfer, which was not used despite the resident's dizziness and fear.
Two residents with PTSD did not receive appropriate care due to incomplete care plans lacking details on triggers, interventions, and goals. Staff were unaware of the residents' PTSD needs, indicating a communication gap. The facility's policy on trauma-informed care was not followed, leading to unmet mental and psychosocial needs.
A facility's medication error rate exceeded the acceptable threshold of 5%, with two errors observed. An LPN crushed and administered Januvia against label instructions, resulting in a dosing error for a resident with Type 2 diabetes. Another resident did not receive their prescribed levothyroxine due to it not being available, despite it being in the contingency supply, leading to an omission error.
The facility failed to promptly resolve grievances for two residents. One resident requested her catheter flush be scheduled at 8:00 AM to attend activities and church on time, but it was consistently done after 9:00 AM. Another resident reported receiving bedtime medications late and was informed of the resolution four weeks later, violating the facility's policy for timely communication.
A facility failed to report an allegation of verbal abuse involving a resident who was told by staff to "keep his mouth shut" after a spill incident. Another resident overheard and reported the incident, but the facility did not notify the state agency as required by their abuse policy. The Director of Nursing and Social Worker acknowledged the oversight, and the Nursing Home Administrator was unaware of the incident until reviewed with a surveyor.
A facility failed to report and thoroughly investigate an allegation of verbal abuse involving a resident who was told by staff to keep his mouth shut after an incident. Another resident overheard and reported the event, but the facility did not notify the state agency or conduct a proper investigation, as confirmed by the DON and Social Worker.
A resident with multiple mental health diagnoses stayed in the facility beyond the 30-day exemption period without a required PASRR Level II screen. The oversight was due to departmental turnover and changes in the electronic charting system, as acknowledged by the facility's staff.
Two residents experienced significant incidents due to the facility's failure to adhere to care plans and provide adequate supervision. One resident, with severe cognitive impairment, was not transferred according to her care plan, resulting in a fall and a left distal femur fracture. Another resident, at risk for elopement, left the facility unnoticed due to a malfunctioning WanderGuard system. These incidents highlight deficiencies in the facility's safety and supervision protocols.
A resident with severe dementia was restrained and given medication via oral syringe against their apparent refusal, violating their right to refuse medication. The facility's staff did not adhere to the care plan or policies, which emphasize respecting residents' rights and managing agitation appropriately. Interviews with staff confirmed the bypassing of the resident's right to refuse medication.
The facility did not conduct a thorough investigation into an alleged abuse incident involving a resident. Despite reporting the allegation to the state agency, the facility failed to interview key witnesses and staff, including a potential witness identified by a CNA and the supervising nurse of the accused med tech. The Director of Nursing confirmed the absence of additional interviews and related audits or education, highlighting a deficiency in the facility's investigation process.
A resident with increased exit-seeking behaviors was not provided adequate supervision, leading to an elopement incident. Despite documented wandering and confusion, the facility failed to reassess the resident's elopement risk or update the care plan. The incident was not recorded in the resident's electronic health record, contrary to facility policy.
The facility did not ensure all drugs and biologicals were stored and labeled in accordance with professional principles, leading to the administration of expired medications. An expired Aspirin tablet was given to a resident, and additional expired and unlabeled medications were found in other medication carts. Interviews confirmed that the facility's policies were not consistently followed.
Failure to Prevent Resident-to-Resident Sexual Abuse by Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with a known history of inappropriate sexual behavior. One resident (R1), who had a documented history of touching other male residents inappropriately, was initially placed on 1:1 supervision after incidents on 4/27/25 and 4/28/25 in which he was found with his hands in other male residents’ briefs or crotch areas, touching their genitals. Over the following months, the facility progressively reduced R1’s supervision from 1:1 to 15‑minute checks, then to one‑hour checks, then to two‑hour checks, and ultimately discontinued his supervision entirely on 12/12/25, despite his history of sexually inappropriate conduct. R1’s medical record shows multiple medical conditions, including hemiplegia and hemiparesis following a stroke, diabetes mellitus, hypertension, and other cardiovascular conditions. His MDS documented a BIMS score of 10, indicating moderate cognitive impairment, and noted physical and verbal behaviors directed toward others. His care plan identified a behavior problem of inappropriate sexual conduct with other residents and inappropriate comments to staff, and included interventions such as providing care in pairs and, later, specific directions to intervene, remove him from other residents’ rooms, and protect the rights and safety of others. Staff interviews confirmed that R1 was known to be sexually inappropriate, particularly with male residents, and that interventions such as 1:1 supervision when up in his wheelchair, 15‑minute checks when in bed or recliner, and a door alarm were in place at the time of the survey. On 1/18/26, after supervision had previously been discontinued and then later re‑implemented, R1 was found in another resident’s (R2’s) room inappropriately touching R2 in his private area under his clothing. R2, who had diagnoses including acute respiratory failure with hypoxia, COPD, sepsis, Alzheimer’s disease, and hypertension, was documented as cognitively intact on his MDS, able to understand and be understood, and having no behaviors. Witness accounts from staff indicated that R1’s hand was inside R2’s pants, touching R2’s penis and upper thigh, and R2 stated that the touching was not consensual. The facility’s abuse, neglect, and exploitation policy required prevention of abuse, identification and monitoring of residents with behaviors that might lead to conflict, and increased supervision to protect residents from harm, but the facility’s reduction and discontinuation of R1’s supervision, despite his known history of sexually inappropriate behavior, led to the incident of non‑consensual sexual contact. Surveyors determined that this failure to provide adequate supervision and protect residents from sexual abuse created a reasonable likelihood for serious psychosocial harm and resulted in a finding of Immediate Jeopardy beginning on 1/18/26.
Removal Plan
- Residents were separated and the incident was reported to the NHA.
- Staff provided statements; additional staff interviews were completed as needed.
- Law enforcement responded and interviewed the residents.
- Residents had mood, behavior, and appetite monitored.
- Residents received skin assessments.
- Residents’ physicians were updated; the POA was updated; the resident who is their own decision maker declined notification.
- All residents on the wing with a BIMS less than 7 received skin checks.
- All residents with a BIMS greater than 7 were interviewed.
- The resident was placed on 1:1 supervision when up in a wheelchair.
- The resident was placed on 15-minute checks when in bed or recliner.
- Alarms were implemented on the resident’s door and at ground level to alert staff.
- Residents’ psychosocial well-being care plans were updated.
- Resident relationship, intimacy, and sexuality histories were completed; both residents denied wanting a relationship.
- Staff education was initiated regarding abuse with emphasis on sexual abuse, 1:1 definition and expectations, resident-specific interventions, and 15-minute checks; charge nurse and leadership ensured staff were educated prior to the start of their shifts.
- The social worker interviewed the residents and both stated they feel safe.
- The DON and VP of Nursing interviewed the resident and the resident stated they feel safe.
- BCS services were offered to the residents and both declined.
- The resident was offered materials to help with hypersexuality and declined.
- A care plan meeting was held with the resident, the facility, and the POA to discuss behaviors, the plan moving forward, and activities of interest.
- The Medical Director was updated regarding the incident between the residents.
Failure to Implement and Communicate Abuse Prevention Interventions
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of dementia was subjected to inappropriate sexual contact by another resident, who also had severe cognitive impairment and behavioral disturbances. The incident occurred in a common area and was witnessed by a registered nurse, who intervened and separated the residents. The nurse reported the incident to the nurse manager later in the day after being advised by another nurse that it needed to be reported. The initial response included documenting the incident and notifying management. Following the incident, the care plan for the resident who committed the inappropriate act was updated to include 1:1 supervision and the installation of a motion sensor alarm on the resident's doorway and bathroom. However, during subsequent observations, these interventions were not consistently implemented. Staff were observed leaving the resident unsupervised in common areas, and the motion sensor alarm did not always function as intended. Additionally, the care plan interventions were not reflected in the CNA Kardex, and staff were not consistently aware of the required supervision or interventions. Interviews with multiple staff members revealed a lack of awareness and education regarding the updated care plan interventions. Some staff had not received any education since returning from leave, and there was confusion about how care plan changes were communicated and implemented. The facility's documentation showed that only a fraction of the staff had signed off on education related to the incident, indicating a gap in staff training and communication. These failures resulted in the resident not being adequately protected from further abuse, as required by regulations.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for two of five Certified Nursing Assistants (CNAs) reviewed. Specifically, one CNA hired on 5/3/23 and another hired on 2/10/23 did not have documented annual performance evaluations for 2024. This deficiency was identified through interview and record review, with the Director of Nursing confirming that yearly evaluations are expected for all CNAs.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene during wound care for a resident. During an observed wound care procedure, a registered nurse performed hand hygiene initially and donned gloves and a gown before removing the resident's old bandage. However, after removing gloves at multiple points during the procedure, the nurse did not perform hand hygiene before donning new gloves, contrary to facility policy and physician orders. The nurse continued the wound care process, including cleansing and dressing the wound, without appropriate hand hygiene between glove changes. Interviews with the nurse and the Director of Nursing confirmed that hand hygiene should have been performed after each glove removal, and both acknowledged that this was not done during the observed procedure. The facility's policies on clean dressing changes and hand hygiene specifically require handwashing after glove removal to prevent infection and cross-contamination, but these protocols were not followed during the care of the resident with a left knee wound.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility is experiencing a significant COVID-19 outbreak affecting all six units, with 38 residents and 18 staff members testing positive. The outbreak began when three residents and one staff member tested positive, and the facility failed to implement effective infection control measures. Staff were observed improperly doffing PPE in the hallway, contaminating clean PPE with dirty PPE, and not adhering to proper hand hygiene protocols. Additionally, the facility did not document COVID-positive residents' signs and symptoms on the line list or elsewhere, and agency staff were not fit tested for N95 masks. The facility's infection preventionist, who recently assumed the role, was not provided with adequate training before starting. The infection preventionist admitted to not documenting symptoms on the line list and not conducting group education on PPE usage. The Director of Nursing acknowledged that the facility should have tested residents R16 and R19 when they first showed symptoms, but testing was delayed by a day. The facility also failed to fit test agency staff for N95 masks, which is a critical component of the infection control program. Observations by the surveyor revealed that staff members were not following proper PPE protocols. Staff were seen exiting a COVID-positive room with PPE on, removing it in the hallway, and placing used PPE on the isolation cart, which led to contamination. The staff also failed to perform hand hygiene before applying new masks. These actions demonstrate a breach in infection control practices, contributing to the spread of COVID-19 within the facility.
Violation of Residents' Visitation Rights
Penalty
Summary
The facility failed to honor the residents' rights to receive visitors of their choosing at the time of their choosing for two residents, R1 and R4. R1's medical record and a sign at the nurses' station indicated that R1's son, daughter, and daughter-in-law were not allowed to visit, based on the wishes of R1's Power of Attorney (POA), despite R1 being cognitively intact and expressing a desire to visit with them. The facility's actions were based on the POA's instructions, which were not legally supported as the POA only had authority over health care decisions, not visitation rights. Similarly, R4's medical record and a sign at the nurses' station indicated that a family member, FM E, was not allowed to visit, based on the request of R4's POA. R4 had moderate cognitive impairment, and the facility acted on the POA's request without legal authority, as the POA's power was limited to health care decisions. Staff were instructed to ask FM E to leave if they attempted to visit, and if they refused, to contact the administrator. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed a lack of understanding regarding the limitations of a POA's authority over visitation rights. The staff believed that the POA could restrict visitors, which contradicted the residents' rights to have visitors of their choosing. The facility's actions were not aligned with the residents' rights as outlined in their own handouts and policies, which emphasized the residents' rights to private and unrestricted visits.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure that residents were free from sexual abuse, as evidenced by an incident involving two residents, R2 and R3. R3, who has severe cognitive impairment due to vascular dementia, was found in R2's room, sitting on the edge of R2's bed with R2's Depends unfastened, and fondling R2 between the butt cheeks. R2, who also has severe cognitive impairment, remained asleep during the incident and showed no signs of pain or emotional disturbance. The incident was reported to the Nursing Home Administrator, and an investigation was initiated. The facility's policy on abuse, neglect, and exploitation requires the development and implementation of written policies and procedures to prevent such incidents. However, the facility did not put any new interventions in place after the incident to prevent it from happening again. R3 was placed on 15-minute checks, but there was no documentation in R3's medical record to confirm this. Additionally, the care plans for both R2 and R3 were not updated following the incident, and no specific measures were taken to ensure the safety of other residents. The Director of Nursing and the Nursing Home Administrator acknowledged that the incident was not reported to the state agency within the required two-hour timeframe. Furthermore, not all staff received abuse training following the incident, with only 117 out of 175 staff members having completed the training. The facility's failure to implement adequate protective measures and update care plans after the incident highlights a deficiency in ensuring resident safety and compliance with abuse prevention policies.
Delayed Reporting of Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident within the required timeframe as per their policy. The incident involved two residents, where one resident was found by a CNA sitting on the edge of another resident's bed, with the latter's brief pulled down and being touched inappropriately. The incident was discovered at approximately 4:30 AM, but the report to the State Agency was not made until 10:39 AM, exceeding the 2-hour reporting requirement for abuse allegations. The facility's policy mandates that such incidents be reported immediately, but no later than 2 hours after the allegation is made. The residents involved were both non-interviewable, with low BIMS scores indicating cognitive impairment. The resident who was touched did not exhibit signs of pain or emotional disturbance and remained asleep during the incident. The facility's interim administrator was informed of the incident at 9:00 AM, and the Director of Nursing was notified at 6:17 AM. Despite these notifications, the report to the State Agency was delayed, and the facility initially considered the incident as a resident-to-resident altercation rather than abuse, which contributed to the reporting delay.
Failure to Investigate and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an accusation of physical abuse involving two residents. One resident was found in another resident's room, sitting on the edge of the bed with the other resident's brief unfastened, and was observed fondling the resident. The facility did not implement measures to prevent a recurrence of this incident, nor did it provide abuse education to all staff members. The facility's policy on abuse, neglect, and exploitation requires the development and implementation of written policies and procedures to prohibit and prevent abuse, including the establishment of a safe environment and the identification and monitoring of residents with behaviors that might lead to conflict. However, after the incident, the facility did not update the care plans for the involved residents, nor did it document any increased supervision or monitoring of the resident who was the alleged perpetrator. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that no specific interventions were put in place to ensure the safety of the residents involved or other residents in the facility. The DON acknowledged that no new interventions were implemented following the incident, and the NHA considered the incident isolated, not warranting facility-wide staff education. The lack of documentation and follow-up actions highlights the facility's failure to adhere to its own policies and procedures regarding abuse prevention and response.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and manage pressure injuries for a resident identified as R2. R2, who was at high risk for pressure injuries due to conditions such as cerebral palsy and schizophrenia, developed a Stage 3 pressure injury on the right ischium. The facility did not implement appropriate interventions for pressure injury prevention despite being aware of R2's high risk status as indicated by a Braden Scale score of 12, which signifies a high risk for skin breakdown. The facility's policy on pressure injury prevention and management was not followed, as no skin interventions were in place prior to the development of the Stage 3 pressure injury. The deficiency was further compounded by the lack of timely and appropriate response once the pressure injury was discovered. The facility's records show that the pressure injury was not identified until it had progressed to Stage 3, and there was a delay in notifying the physician and implementing a treatment plan. The facility's Director of Nursing (DON) confirmed that no skin interventions were in place before the injury was discovered and acknowledged that this was not acceptable. Additionally, there was no evidence of a root cause analysis being conducted to understand how the pressure injury developed to such an advanced stage. Observations and interviews with staff revealed inconsistencies in wound care management, including instances where R2's dressing was not in place, particularly during the night shift when agency staff were more frequently on duty. The dressing was often found to be off or soiled, and there was a lack of communication and follow-up to ensure the dressing was reapplied promptly. The DON admitted that there was no education provided to staff following the discovery of the pressure injury, and there was an indication that some staff were not diligent in changing R2's dressing, which further contributed to the deficiency.
Failure to Monitor and Address Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R11, maintained acceptable nutritional and hydration status, resulting in severe weight loss. R11 experienced a weight loss of 20.6 pounds, or 12.86%, over a period of two months and ten days. Despite being added to the facility's Critical At Risk monitoring, R11's care plan was not updated to address her nutritional status or risk, and she continued to be listed as overweight. The facility's policy required monthly weight checks, but R11 was not weighed in November, and there was no documentation of refusals to be weighed. R11's meal intake records showed inconsistent consumption, with 38% of recorded meals indicating less than 50% intake. Despite this, no new dietary interventions were implemented in November or December. The registered dietician (RD) was aware of R11's poor intake and significant weight loss but did not document any follow-up on a recommendation for mirtazapine, an appetite stimulant. Additionally, the RD was not informed of R11's cognitive decline, which could have warranted further assessment and intervention. The facility's failure to monitor R11's weight and meal intake consistently, along with the lack of appropriate interventions, contributed to her severe weight loss. The registered dietician's recommendations were not documented as being followed up on, and there was no evidence of reassessment of R11's ability to feed herself following a decline in her cognitive status. This lack of action and communication among staff members led to R11's continued weight loss and nutritional decline.
QAA Committee Lacks Required Members and Quarterly Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required members and did not meet the quarterly attendance requirements. Specifically, the QAPI meetings for February and June 2024 did not include the Director of Nursing (DON) or the Infection Preventionist (IP), which are mandatory members according to the facility's policy. The facility's QAPI plan did not list the IP as a member, which is a deviation from the policy that requires the IP's presence. This oversight has the potential to affect all 90 residents residing within the facility. During the survey, it was noted that the QAPI sign-in sheets for the first and second quarters of 2024 lacked signatures from the DON and IP, while the third and fourth quarters had all required members present. The Nursing Home Administrator (NHA) confirmed the accuracy of the attendance records and acknowledged the absence of the DON and IP in the meetings. The NHA also failed to mention the IP as a regular attendee when asked about the committee's composition, indicating a lack of adherence to the established QAPI policy.
Inadequate Infection Control and Water Management Program
Penalty
Summary
The facility failed to establish and maintain an effective Infection Control Program, which included a water management program to prevent the spread of Legionella. Despite having policies in place, the facility did not have an active water management team, and the necessary documentation, such as the water management program binder, was missing. The Maintenance Director admitted that the binder was discarded by a previous employee, and there were no routine meetings to discuss water management and infection control risks. Although Legionella tests were conducted, the lack of a comprehensive program and team meetings indicates a significant oversight in infection prevention. Additionally, the facility did not adhere to proper laundry handling procedures, as observed by the surveyor. Clean linens were transported uncovered through common areas and stored inappropriately close to soiled laundry. The housekeeping staff did not have access to appropriate personal protective equipment, such as gowns or aprons, when handling dirty laundry. The Infection Preventionist acknowledged that clean laundry should be covered and that gowns should be available for staff, highlighting a failure to follow established infection control policies. Furthermore, a resident who exhibited signs of infection, including a low-grade fever and emesis, was not added to the facility's infection control line list. The Infection Preventionist was not informed of the resident's symptoms, which is a breach of the facility's policy to monitor and document potential infections. This oversight in communication and documentation further demonstrates the facility's inadequate infection control practices.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that snacks were consistently offered to residents at bedtime when there were more than 14 hours between the evening meal and breakfast. This deficiency was observed to potentially affect all 90 residents across all six units. Residents voiced concerns about not being offered snacks at bedtime, and staff from various halls confirmed that snacks were not consistently provided. The facility's policy required that all residents be offered a bedtime snack unless specified otherwise in their care plan, but this was not being adhered to. Observations and interviews revealed that meals were often served late, with breakfast being served 55 minutes past the scheduled time on one occasion. Staff members, including CNAs and an RN, indicated that snacks were not routinely offered at bedtime, and the facility no longer used a snack cart. The Dietary Manager and Regional Food Service Director acknowledged the 15-hour gap between supper and breakfast and confirmed that nursing staff were expected to offer snacks, but this was not happening consistently. The Nursing Home Administrator also reviewed the facility's snack policy and acknowledged the deficiency.
Sanitation and Food Safety Deficiencies in Facility's Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in its food preparation, storage, and distribution areas, potentially affecting all 90 residents. Multiple staff members, including the Dietary Manager, Certified Nursing Assistant, Dietary Supervisor, and Regional Dietary Director, were observed in the food preparation area without wearing required hair restraints, violating the facility's Uniform Dress Code policy. Additionally, the Dining Room Attendant was seen stacking wet dishes, which led to a white film buildup and condensation inside the cups and mugs, contrary to the facility's policy on air drying dishes. The surveyor also noted several issues with food storage and equipment cleanliness. Dented cans were found in circulation, and opened food items were not labeled or dated as required by the facility's Food and Supply Storage policy. Furthermore, stored kitchen equipment, such as mixers and a microwave, were found with food particles, indicating they had not been cleaned properly before storage. These observations were confirmed by the Dietary Manager and Regional Dietary Director, who acknowledged the lapses in following the facility's policies.
Insufficient Staffing in Food Service Leads to Delayed Meals
Penalty
Summary
The facility failed to ensure a sufficient number of trained staff in the food service department, resulting in delayed meal services for several residents. Observations and interviews revealed that meals were consistently served late, with breakfast and lunch being delayed by up to 55 minutes past the scheduled times. Residents expressed concerns about the timeliness of their meals, and one resident documented the delays over several weeks, showing a pattern of late meal service. The facility's meal schedule was not adhered to, and the dietary staff did not record the actual times meals were delivered to the wings. The deficiency affected multiple residents, including those with complex medical conditions such as hyperlipidemia, heart disease, and vascular dementia. Despite the facility's meal schedule outlining specific times for meal service, the dietary staff failed to deliver meals on time, and there was a lack of coordination in the food service process. Interviews with the Dietary Manager and Regional Director confirmed that the staff should follow the scheduled times, but there was no system in place to track the actual delivery times, contributing to the ongoing issue of late meal service.
Failure to Adhere to Resident Council Policy and Meeting Autonomy
Penalty
Summary
The facility failed to adhere to its policy regarding the Resident Council, which resulted in deficiencies related to the handling of grievances and the autonomy of resident meetings. The policy mandates that the management team must respond to concerns, complaints, or recommendations within 10 business days. However, residents reported that they only received follow-ups at the subsequent monthly Resident Council meetings, which is a delay from the stipulated timeframe. This lack of timely communication was confirmed by the Social Worker and the Nursing Home Administrator, who acknowledged the facility's failure to comply with its policy. Additionally, the facility did not respect the residents' right to hold meetings without staff presence, as required by the facility's policy. Residents expressed that the previous administrator attended meetings uninvited, which was against their wishes. This intrusion into the Resident Council meetings was corroborated by both the Social Worker and the Nursing Home Administrator, who confirmed that residents should be allowed to meet independently. The Resident Council minutes and grievance forms highlighted several unresolved issues, such as delayed responses to call lights, inconsistent medication administration times, and inadequate staffing levels. These concerns were documented but not addressed within the required timeframe, further illustrating the facility's failure to act promptly on resident grievances. The facility's inaction and disregard for the established policy contributed to the residents' dissatisfaction and the deficiency noted by the surveyors.
Facility Fails to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, as evidenced by the cold water temperatures in the shower rooms. Resident R391, who has a moderately intact cognitive status, reported that the showers have been cold since admission. During an interview, the surveyor confirmed the water temperature in the shower room was 67.7°F, which decreased to 64.4°F after running for six minutes, remaining cold to the touch. A sign in the shower room suggested turning on additional water sources to warm the shower water, but this did not increase the temperature. Resident R42, who is cognitively intact, also reported that the showers were usually cold and uncomfortable. The Maintenance Director, who has been at the facility for eight months, was unaware of the process for checking water temperatures and confirmed there were no records of such checks. The Nursing Home Administrator expected maintenance staff to know the appropriate water temperatures and the facility's policy on safe water temperatures, but this was not the case. The facility's failure to ensure appropriate water temperatures compromised the residents' comfort and safety.
Failure to Ensure Safe Charging of Motorized Wheelchairs and Proper Resident Transfer
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for residents using motorized wheelchairs. The surveyor observed a motorized wheelchair battery being charged in the 600 hall dining room, not behind a fire-safe door, which is against safety protocols. The Director of Nursing (DON) acknowledged that batteries should be charged behind a fire-safe door to prevent fire hazards due to shock or spark. However, the DON was unaware that staff were charging the electric wheelchair in the activity area and had not addressed the issue at the time of the survey. Additionally, the facility did not provide adequate supervision during the transfer of a resident who was feeling ill and dizzy. The resident, who was severely cognitively impaired and required supervision or assistance during transfers, was assisted by two CNAs without the use of a gait belt, despite the resident expressing feelings of dizziness and fear. The Licensed Practical Nurse (LPN) who witnessed the transfer confirmed that a gait belt should have been used, and the resident's care plan indicated the need for caregiver assistance with a four-wheeled walker.
Deficiency in PTSD Care Planning for Residents
Penalty
Summary
The facility failed to ensure that residents diagnosed with mental disorders or psychosocial adjustment difficulties, specifically PTSD, received appropriate treatment and services. Two residents, R41 and R65, were identified as not having comprehensive care plans that addressed their PTSD diagnoses. R41's care plan lacked details on known triggers, personalized interventions, and goals related to her past trauma, despite her history of PTSD linked to a prior medical procedure. The care plan only addressed her mood problems related to major depressive disorder without specific interventions for PTSD. R65, diagnosed with PTSD, schizotypal disorder, obsessive-compulsive disorder, and major depressive disorder, also did not have a personalized care plan addressing his PTSD. His initial assessment failed to gather specific information about the origin of his PTSD, its manifestations, triggers, or interventions. Staff members, including a CNA and RN, were unaware of R65's PTSD diagnosis and the necessary interventions, indicating a lack of communication and documentation regarding his mental health needs. The facility's policy on comprehensive care plans emphasizes the need for trauma-informed care, which was not reflected in the care plans for R41 and R65. The Director of Nursing and Social Worker acknowledged the deficiencies in the assessments and care plans, confirming that they should have included detailed information on the residents' PTSD, its manifestations, triggers, and personalized interventions. This oversight highlights a significant gap in the facility's approach to managing residents with PTSD, failing to meet their mental and psychosocial needs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 5.71% error rate observed during a medication pass involving 35 opportunities. Two specific errors were identified. In the first instance, a Licensed Practical Nurse (LPN) was observed crushing and administering Januvia to a resident, despite the medication's label instructions stating it should not be split, crushed, or chewed. This action resulted in a dosing error for the resident, who had a physician's order for Januvia to be taken whole for the management of Type 2 diabetes mellitus without complication. In the second instance, another resident did not receive their prescribed dose of levothyroxine due to the medication not being available at the time of administration. The LPN acknowledged the absence of the medication, and it was later confirmed by the Director of Nursing (DON) that the medication was available in the Omnicell contingency supply and should have been administered. This oversight resulted in an omission error, as the resident's physician had ordered levothyroxine to be administered daily, excluding Sundays, for the treatment of hypothyroidism.
Failure to Promptly Resolve Resident Grievances
Penalty
Summary
The facility failed to promptly resolve grievances for two residents, R40 and R34, as required by their grievance policy. R40, who has multiple sclerosis and is dependent on staff for all care, requested that her morning catheter flush be scheduled at 8:00 AM to allow her to attend activities and church on time. Despite this request, the facility consistently performed the flush after 9:00 AM, causing R40 to miss activities and be late for church. This grievance was voiced to the Nursing Home Administrator and Director of Nursing in August, but there was no documentation or follow-up on the grievance, and the issue persisted. R34 also experienced a delay in the resolution of her grievance. She reported receiving her bedtime medications late, and although the facility reeducated nurses on medication administration time frames, R34 was not informed of the resolution until four weeks later. This delay in communication violated the facility's policy, which states that residents should be informed of grievance resolutions in a timely manner. The facility's failure to document and address these grievances promptly indicates a lack of adherence to their grievance policy. The policy requires prompt efforts to resolve grievances, including acknowledging complaints and actively working towards a resolution. The facility's inaction in these cases resulted in ongoing issues for the residents, highlighting a deficiency in their grievance handling process.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident, identified as R16, to the State Survey Agency. The incident involved a staff member telling R16 to "keep his mouth shut" after water was spilled on him and the floor. This incident was reported by another resident, R19, who overheard the exchange and noted the staff's tone was louder than normal. Both R16 and R19 reported the incident during a Resident Council Meeting, but the facility did not take the necessary steps to report the allegation to the Nursing Home Administrator or the state agency as required by their abuse policy. The facility's abuse policy mandates that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made. Despite this, the grievance investigation dated 11/5/24 showed that the facility did not report the incident to the state agency. The Director of Nursing and the Social Worker acknowledged the failure to report the allegation, and the Nursing Home Administrator was unaware of the incident until it was reviewed with the surveyor. This oversight indicates a lapse in the facility's adherence to its own policies regarding the reporting of abuse allegations.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency. This deficiency was identified for one of the three residents reviewed for abuse. A resident, R16, reported an incident where a staff member told him to keep his mouth shut after water was spilled on him and the floor. Another resident, R19, overheard this interaction and reported it to the staff and during a Resident Council Meeting. Despite these reports, the facility staff did not report the allegation of abuse to the Nursing Home Administrator or the state agency. The facility's abuse policy requires an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. However, the Director of Nursing and the Social Worker acknowledged that a thorough investigation was not conducted regarding this allegation of verbal abuse. The grievance investigation noted that R16 could not remember who the staff member was, and the resolution was to provide continual education to all staff. The Nursing Home Administrator also confirmed that the facility did not conduct a thorough investigation of the allegation.
Failure to Complete PASRR Level II for Extended Stay
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) Level II for a resident who stayed longer than the initially anticipated short-term period. The resident, identified as R65, was admitted with several mental health diagnoses, including Schizotypal disorder, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, and Major Depressive Disorder. Initially, a PASRR Level 1 screen was completed, indicating a short-term stay of 30 days or less, exempting the resident from a Level II screen. However, the resident remained in the facility beyond the 30-day exemption period without a subsequent Level II screen being conducted. The oversight was acknowledged by the facility's social worker and nursing home administrator, who admitted that the PASRR Level II screen should have been completed once it was clear the resident's stay would exceed 30 days. The failure to conduct the necessary screening was attributed to departmental turnover and changes in the electronic charting system, which led to the oversight. Despite the resident's continued stay in the facility, the required PASRR Level II screen was not performed, resulting in a deficiency.
Deficiencies in Resident Supervision and Care Plan Adherence
Penalty
Summary
The facility failed to ensure a safe environment free from hazards and did not provide adequate supervision and assistive devices for two residents, leading to significant incidents. One resident, R2, who had severe cognitive impairment and a history of falls, was not transferred according to her care plan, which required the use of an EZ stand with one assist. Instead, a CNA performed a pivot transfer, resulting in R2 being lowered to the floor when her knees buckled. This incident led to R2 sustaining a left distal femur fracture, which required surgical intervention. The failure to follow the care plan was identified as neglect, and the involved staff member was terminated. Another resident, R1, who was at risk for elopement due to severe dementia, managed to leave the facility without staff awareness. R1 was wearing a WanderGuard, which failed to alarm when she exited the Memory Care Unit. She was found approximately 0.3 miles away from the facility by a witness. The facility's elopement and wandering policy was not effectively implemented, as staff did not notice R1's absence until she was reported missing. The investigation revealed issues with the WanderGuard system, including a malfunctioning antenna, which contributed to the failure to alert staff of R1's exit. Both incidents highlight deficiencies in the facility's adherence to care plans and supervision protocols. R2's care plan was not followed, leading to a preventable injury, while R1's elopement risk was not adequately managed, resulting in her unsupervised departure from the facility. These deficiencies indicate a lack of compliance with established safety and supervision policies, compromising resident safety.
Resident's Right to Refuse Medication Bypassed
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, was treated with dignity and respect, as required by regulations. R5, who has severe dementia with agitation, was subjected to physical restraint when a Med Tech (MT E) held R5's arms down to administer medication via an oral syringe. This action was taken despite R5's apparent refusal to take the medication, as evidenced by R5's combative behavior, including swinging arms and attempting to bite. The facility's policy on medication administration and dementia care emphasizes the importance of respecting residents' rights, including the right to refuse medication, which was not upheld in this instance. R5's medical history includes Alzheimer's disease, severe dementia with psychotic disturbance, and agitation, and the resident is under palliative care. The Minimum Data Set (MDS) indicates severe cognitive impairment and behavioral symptoms, including physical and verbal behaviors and rejection of care. Despite these documented behaviors, the facility staff did not adhere to the comprehensive care plan, which outlines strategies for managing R5's agitation and refusal of care, such as providing positive interaction, explaining procedures, and allowing the resident to adjust to changes. Interviews with facility staff, including MT E, MT F, RN K, and the Hospice Case Manager, revealed a lack of adherence to the resident's right to refuse medication. MT E admitted to bypassing R5's refusal by administering medication through an oral syringe, a method not authorized by the physician's orders. Other staff members acknowledged that using an oral syringe could bypass R5's right to refuse medication. The Director of Nursing confirmed that residents have the right to refuse medications, and using an oral syringe in this manner bypasses that right.
Failure to Conduct Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident. On 7/9/24, the facility reported the allegation to the state agency but did not complete a comprehensive investigation as required by their policy. The policy mandates immediate investigation, including identifying and interviewing all involved parties, such as the alleged victim, perpetrator, witnesses, and others with potential knowledge of the incident. However, the facility did not interview a potential witness identified by a CNA, nor did they interview the supervising nurse of the accused med tech or other staff who may have been involved or present during the incident. The surveyor's review on 8/1/24 revealed that the facility's investigation was incomplete, lacking interviews from key individuals who could provide relevant information about the alleged abuse. The Director of Nursing confirmed the absence of additional documented interviews and acknowledged that no audit or educational measures were associated with the allegation. This lack of thorough investigation and documentation constitutes a deficiency in the facility's handling of the abuse allegation.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident identified as having increased exit-seeking behaviors. Despite the resident's initial assessment indicating no risk for elopement, subsequent behaviors such as wandering at night and expressing confusion were documented in the nurse's notes. These behaviors included looking for a way to leave the facility and expressing a desire to go home, which were not adequately addressed by the facility's staff. The resident eventually eloped from the facility, as noted in a self-report submitted by the Nursing Home Administrator. The report indicated that the resident was found outside the facility, attempting to find a police station. There was no documentation in the resident's electronic health record regarding the elopement, nor evidence of increased supervision or reassessment of the resident's elopement risk. The Director of Nursing confirmed that the facility's policy was not followed, as the resident's care plan did not include interventions for wandering or elopement risk, and the incident was not documented as expected.
Expired and Unlabeled Medications Found in Medication Carts
Penalty
Summary
The facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure expired medications were removed from medication carts. This deficiency was observed in 3 of 4 medication carts/storage rooms. Specifically, an expired Aspirin tablet was administered to a resident (R6) during medication administration. The resident had multiple diagnoses including hyperlipidemia, tachycardia, essential hypertension, diabetes mellitus type 2, asthma, and a pressure ulcer. The physician's orders required the administration of Aspirin 81 mg Enteric Coated (EC) daily. However, the Aspirin bottle used was unlabeled with no open date and had a manufacturing expiration date of 03/2024, which had already passed at the time of administration. Further observations revealed additional expired and unlabeled medications in other medication carts. For instance, the medication cart on the 600 wing contained an opened Aspirin bottle with an expired date, a Simethicone tab bottle with an expired date, and a Nitroglycerin bottle with no visible expiration date. Similar issues were found in the medication carts on the 100 and 300 wings. Interviews with the nursing staff and the Interim Director of Nursing (DON) confirmed that the facility's policy required labeling bottles with the open date and checking expiration dates before administration, but these procedures were not consistently followed. The DON acknowledged the need for improvement and indicated that medication carts were not being monitored consistently.
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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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