Newcastle Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Mequon, Wisconsin.
- Location
- 12600 N Port Washington Rd #300, Mequon, Wisconsin 53092
- CMS Provider Number
- 525668
- Inspections on file
- 23
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Newcastle Place during CMS and state inspections, most recent first.
Staff left whole medications at the bedside for a severely cognitively impaired resident with metabolic encephalopathy and hypertension without conducting a self-administration assessment, obtaining an MD order, or developing a related care plan, despite facility policy requiring an IDT-based determination of decision-making capacity before allowing self-administration. The resident’s family later found two pills on the bedside table, which a nurse indicated might have been antihypertensive medication, and the Administrator acknowledged the resident would not have been able to self-administer medications.
A resident with severe cognitive impairment and HTN was ordered carvedilol 25 mg PO BID with no authorization for self-administration. An LPN documented giving the evening dose, but whole medications, later identified by family as likely carvedilol and atorvastatin, were left in a medicine cup at the bedside. The next morning, family gave the resident the bedside pills before an LPN arrived to pass meds. While the LPN was administering the scheduled crushed carvedilol dose in applesauce, the family reported the earlier ingestion and described the pills, which the LPN confirmed were likely the resident’s BP medication from the prior shift. The LPN completed administration of the carvedilol in applesauce, after which the resident became drowsy, then unresponsive, with a marked drop in BP and was sent to the ED with hypotension and bradycardia attributed to two doses of carvedilol taken that morning.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report does not specify further details about the residents or staff involved.
Two residents with intact cognition reported missing money and personal property, but the facility did not notify law enforcement or the State Agency as required. Staff documented the incidents and informed the administrator, but there was no evidence of timely reporting to authorities, and the facility did not follow its own abuse and misappropriation reporting policies.
The facility did not thoroughly investigate two separate allegations of misappropriation of resident property. In both cases, residents with intact cognition reported missing money and personal items, but the facility failed to conduct comprehensive investigations, including staff interviews and proper documentation, as required by policy.
A resident independently administered pain medication and insulin brought from home due to a delay in the facility's pharmacy delivery. Staff interviews confirmed that the resident was offered facility-supplied insulin but chose to use their own, and the use of home medications was not documented in the medical record as required by facility policy.
Staff did not consistently wear required hair or beard restraints in food preparation and service areas, and failed to ensure the dishwasher reached proper sanitizing temperatures or document the use of temperature strips. Additionally, staff did not properly test or document the quaternary sanitizing solution in the three-compartment sink, using incorrect test strips and failing to check water temperature as required.
The facility did not conduct required reference checks for four newly hired CNAs, as mandated by its abuse, neglect, and exploitation policy. Staff interviews confirmed that reference checks were not part of the hiring process, and documentation was not maintained, resulting in noncompliance with facility policy.
Four residents with complex medical histories, including diabetes and respiratory conditions, were not offered or administered the PCV20 pneumococcal vaccine despite being eligible under CDC guidelines. The Infection Preventionist was unaware of the updated vaccination requirements and there was no system in place to ensure the PCV20 vaccine was offered.
A resident with a recent BKA and multiple comorbidities did not receive wound care as ordered, with the dressing not changed for several days after admission despite documentation indicating otherwise. The resident also did not have vital signs monitored daily as required by facility policy, and staff interviews confirmed lapses in both care delivery and documentation.
A resident with a history of falls and significant mobility and cognitive impairments did not have their walker kept within reach as required by their care plan. Despite recent falls and documented risk factors, staff did not consistently follow the intervention, and multiple staff members confirmed the walker was not accessible to the resident during observations.
Two residents with PICC lines did not have their dressings and injection caps changed as ordered, despite documentation indicating the tasks were completed. Direct observation and interviews confirmed that the required weekly changes were missed or delayed, contrary to physician orders and facility policy.
Staff did not consistently use required PPE, including gown and gloves, while providing high-contact care to a resident on Enhanced Barrier Precautions for chronic wounds. Despite clear policy, signage, and care plan instructions, CNAs and a restorative aide were observed and admitted to providing care and transfers without proper PPE, and staff interviews confirmed a lack of adherence to infection control protocols.
A facility failed to report a verbal abuse incident involving an LPN and a resident with moderate cognitive impairment. The LPN was witnessed yelling derogatory terms at the resident, who was crying for help. Despite the facility's policy requiring immediate reporting to law enforcement, the incident was not reported. Multiple staff members observed the LPN's abnormal behavior, raising concerns about possible intoxication.
A facility failed to thoroughly investigate a verbal abuse allegation involving a resident with dementia. An LPN was observed verbally abusing the resident, but the investigation lacked interviews with key individuals, notification to law enforcement, and updates to the resident's care plan. The Nursing Home Administrator did not initially provide abuse education, considering it an isolated incident.
A resident did not receive prescribed heparin injections as ordered, with several doses missing from the MAR and no progress notes explaining the omissions. Despite having access to contingency medication and the ability to request STAT orders, the facility failed to administer the medication correctly. Interviews revealed that the Omnicell machine did not record any heparin removal, indicating a lapse in medication administration and documentation.
A CNA failed to follow proper infection control procedures during incontinence care for a resident by not removing gloves and performing hand hygiene after perineal care. The CNA touched various items in the resident's room without cleansing hands, contrary to the facility's hand hygiene policy. The DON confirmed the expectation for staff to perform hand hygiene after removing soiled gloves.
The facility failed to implement its abuse policy for three employees by not completing required background checks. An RN's background check was outdated, and the facility lacked background information for a DM and CNA who were contracted staff.
The facility failed to notify a physician of a resident's low irregular heart rate and low blood pressure and did not follow physician orders for daily weights. The resident was later admitted to the ICU for hypotension.
The facility failed to ensure staff used gait belts during transfers for four residents, despite the expectation and policy to do so. Observations and interviews confirmed that staff often did not use gait belts, compromising resident safety.
The facility failed to ensure accurate medication administration for three residents, leading to missed doses and improper documentation. One resident did not receive timely pain medication, another missed four doses of prescribed medication upon admission, and a third missed two doses due to unavailability. Staff interviews confirmed these issues and highlighted challenges in the medication delivery process.
A resident was administered Benadryl for sleep instead of its prescribed use for itching. The resident, who had intact cognition and multiple diagnoses, requested Benadryl to help sleep. An agency nurse administered it despite the resident not experiencing itching. The facility's policy and nursing leadership confirmed that the medication should only be administered for its prescribed reason.
The facility failed to report allegations of abuse, neglect, or injury to the State Agency and local law enforcement in a timely manner for five residents. Delays were due to administrative oversights and lack of access to reporting portals, leading to non-compliance with regulatory requirements.
The facility failed to thoroughly investigate allegations of abuse for six residents. Investigations lacked interviews with other residents and staff, and in some cases, the accused staff were not removed from resident care pending the investigation's outcome. Additionally, investigations did not summarize or identify the cause of injuries or complete necessary staff education.
The facility failed to protect a resident from abuse by not implementing interventions after staff voiced concerns about a CNA's behavior. Despite reports of abuse and staff identifying the CNA as rude and unkind, the CNA continued to work without documented intervention. The CNA was later implicated in an incident where a resident reported being thrown around in bed, resulting in bruising. The facility lacked documentation and thorough investigation, leading to the CNA's termination.
Failure to Assess and Authorize Self-Administration Before Leaving Medications at Bedside
Penalty
Summary
Facility staff failed to follow their medication administration policy requiring an assessment and physician authorization before allowing residents to self-administer medications. The policy stated that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined they had the decision-making capacity to do so safely. One resident was admitted with diagnoses including metabolic encephalopathy and hypertension, and the admission MDS showed a BIMS score of 5/15, indicating severe cognitive impairment. Despite this, whole medications were left at the bedside over a weekend without any documented assessment of the resident’s ability to self-administer medications. An incident note documented that the resident’s daughter found two pills in the resident’s room on the bedside table, which a nurse indicated might have been blood pressure medication. Review of the resident’s care plan showed there was no care plan addressing self-administration of medications, and review of assessments confirmed the resident had not been evaluated for self-administration. Additionally, physician orders did not include any order to leave medications at the bedside for the resident to self-administer. In an interview, the Administrator acknowledged that the resident would not be able to self-administer medications and noted the resident had previously lived in a memory care unit before admission to the skilled nursing unit.
Duplicate Carvedilol Doses Left at Bedside Lead to Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when duplicate doses of a prescribed blood pressure medication were administered. The resident had diagnoses including metabolic encephalopathy and hypertension and was assessed as severely cognitively impaired with a BIMS score of 5/15. The resident had an order for carvedilol 25 mg by mouth twice daily with meals for hypertension, scheduled for morning and evening, and there was no order or care plan for self-administration of medications. According to the Medication Administration Record, an LPN documented administering the resident’s evening medications, including carvedilol, on the day prior to the incident. The facility’s investigative summary later determined that whole medications, identified by the resident’s daughter as likely carvedilol and atorvastatin, had been left at the bedside by staff from a previous shift. On the morning of the incident, family members arrived and found a couple of pills in a medicine cup on the bedside table; the daughter reported that the resident ingested these pills before the nurse began the morning medication pass. While the LPN was administering the scheduled morning dose of carvedilol crushed in applesauce, the daughter informed the nurse that the resident had just taken two pills from the bedside. The LPN checked the MAR and, after comparing pill appearance with the daughter’s description, concluded the pills were likely the resident’s blood pressure medication from the prior evening. Despite this, the crushed carvedilol dose in applesauce was administered. Within approximately 30–45 minutes, the resident became drowsy, then unresponsive to verbal and tactile stimuli, and vital signs showed a significant drop in blood pressure (78/54) with altered consciousness. The resident was transferred to the ED, where records indicated hypotension and bradycardia after taking two doses of carvedilol earlier that day.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions by staff or details about the residents involved are not provided in the report. No additional information regarding the medical history or condition of any resident at the time of the deficiency is included.
Failure to Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the timely reporting of suspected misappropriation of resident property, as required by section 1150B of the Act. In two separate cases, residents with intact cognition reported missing money and personal property. In the first case, a resident and their family reported $40 and a silver dollar coin missing to a registered nurse, who documented the report and informed the Nursing Home Administrator (NHA) and the on-call nurse. However, there was no documentation that local law enforcement was notified, and the NHA indicated that although the nurse offered to call law enforcement, the resident and family declined, with no documentation to support this claim. In the second case, another resident reported $280 missing from their room. The incident was reported to staff, and the NHA was made aware, but there was no evidence that the allegation was reported to the State Agency or local law enforcement. The NHA provided a $200 gift card to the resident but had little knowledge of the details of the allegation, and the social worker was reportedly working on a grievance that was not yet on file. In both cases, the facility did not follow its own policy requiring the reporting of such allegations to the appropriate authorities within specified timeframes.
Failure to Investigate Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of resident property for two residents. In the first case, a resident with intact cognition reported missing $40 and a silver dollar coin at the time of discharge. The incident was documented by a registered nurse and reported to the Nursing Home Administrator (NHA) and on-call nurse. While the facility interviewed several residents and audited rooms for lockable drawers, there was no evidence that staff interviews were conducted as part of the investigation. The NHA confirmed that only residents were interviewed and staff were not questioned regarding the missing items. In the second case, another resident with intact cognition reported $280 missing from their room. The incident documentation did not indicate that an investigation was completed. Interviews with staff revealed that the resident had reported the missing money to a certified nursing assistant, who in turn reported it to the NHA and social worker. However, the NHA stated they had little knowledge of the allegation and confirmed that a thorough investigation, including interviews with other residents or staff, was not conducted. The facility's policy requires immediate and comprehensive investigation of such allegations, including interviews and documentation, which was not followed in these cases.
Failure to Document Resident's Self-Administration of Home Medications
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, specifically regarding medications brought from home and self-administered by the resident. Upon admission, the resident did not have access to all prescribed medications through the facility, leading the resident to request that their spouse bring pain medication and insulin from home. The resident independently administered these medications, but this was not documented in the medical record. Nursing progress notes lacked documentation of discussions about available medications, and there was no record of the physician being notified that the resident took their own medications due to the delay in pharmacy delivery. Interviews with staff revealed that the resident was offered insulin from the facility's supply but chose to use their own, and that the facility did not have the resident's narcotic medication available until a later pharmacy delivery. The Director of Nursing and LPNs involved confirmed that the administration of home medications was not fully documented in the electronic medical record. The facility's policy requires that all services provided, changes in condition, and resident responses be documented objectively and completely, which was not followed in this instance.
Failure to Maintain Safe and Sanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as evidenced by multiple staff not wearing required hair or beard restraints while in the kitchen and kitchenettes. Observations revealed that staff, including an activity aide, dietary aide, and cook, entered food preparation and service areas without appropriate hair coverings or beard restraints, contrary to both FDA Food Code requirements and the facility's own policies. Staff interviews confirmed a lack of understanding or adherence to these requirements, with some staff believing that hair restraints were unnecessary if their hair was tied back or if their beard was below a certain length, despite policy stating otherwise. Additionally, the facility did not ensure that the mechanical ware washing machine reached the required sanitizing temperatures. During observations, the ware washing machine failed to achieve the necessary 180 degrees Fahrenheit for the sanitizing cycle, and there was no evidence that alternative sanitization methods were consistently or properly used for dishes and utensils. Documentation reviewed for ware washing cycles did not reflect the actual temperatures observed, and there was no documentation that internal surface temperature strips were used to verify proper sanitization, as required by both FDA Food Code and facility policy. The facility also failed to properly test and document the use of quaternary sanitizing solution in the three-compartment sink. Staff did not test the water temperature when using the sanitizer, and used incorrect test strips to check the sanitizer's concentration. Manufacturer instructions for the sanitizer required testing at specific temperatures and with the correct test strips, but these procedures were not followed. The facility's logs did not include a place to document the temperature of the sanitizing compartment, and staff were observed using the sanitizer at temperatures far above the recommended range.
Failure to Complete Required Reference Checks for New CNAs
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy regarding employee screening for four Certified Nursing Assistants (CNAs). According to the facility's policy, all potential employees are required to undergo background, reference, and credentials checks, including attempts to obtain information from previous or current employers. However, upon review, the surveyor found that reference checks were not completed for any of the four CNAs reviewed. Documentation of reference checks was not provided for these employees, despite their recent hire dates. Interviews with facility staff, including the Nursing Home Administrator (NHA), Human Resources Assistant (HRA), and Director of Human Resources (DHR), confirmed that reference checks were not being conducted as part of the hiring process. The DHR acknowledged awareness of the policy requirement but stated that reference checks were not included in the onboarding package from the corporate office. The NHA indicated that the issue had been raised with corporate personnel but no changes had been made, and the policy continued to be disregarded.
Failure to Offer or Administer PCV20 Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were offered or administered to four residents, as required by current CDC guidelines. Specifically, the medical records for these residents showed that although they had previously received PPSV23 and PCV13 vaccines, there was no documentation that they were offered or administered the PCV20 vaccine. The residents involved had various medical conditions, including diabetes, respiratory failure, discitis, pleural effusion, asthma, ulcerative colitis, and myelopathy. All were of an age that made them eligible for the updated vaccination protocol, and none had documentation of refusal or contraindication for the PCV20 vaccine. During an interview, the facility's Infection Preventionist stated that it was their understanding that no further pneumococcal vaccinations were needed for these residents and acknowledged there was no system in place to offer the PCV20 vaccine. Upon review of the CDC guidelines presented by the surveyor, the Infection Preventionist confirmed the oversight and indicated a lack of awareness regarding the need to offer the PCV20 vaccine to eligible residents.
Failure to Provide Ordered Wound Care and Vital Sign Monitoring
Penalty
Summary
A resident with a right below-the-knee amputation (BKA), sepsis, gangrene, diabetes, hypertension, and a history of thyroidectomy was admitted to the facility and was responsible for their own healthcare decisions. The resident had a physician's order for specific wound care to the BKA site, including cleansing, application of Xeroform, ABD pad, Kerlix, and Ace or Coban wrap every evening shift every other day, and as needed. Despite this order, the resident reported that the surgical incision dressing had not been changed since admission, and the surveyor observed the dressing was dated several days prior. Documentation in the Treatment Administration Record (TAR) indicated dressing changes were completed on certain dates, but the resident and physical evidence contradicted this, and the Director of Nursing (DON) later confirmed that at least one dressing change was not completed as documented. Additionally, the facility's policy required daily vital sign monitoring for residents receiving skilled services. The resident expressed concern that their blood pressure was not being monitored, which was significant given their medical history. Review of the medical record showed no documentation of vital signs being obtained on at least one day, and the DON verified that vital signs were not monitored as required. Staff interviews revealed inconsistent understanding and implementation of the facility's policies regarding vital sign monitoring and wound care documentation.
Failure to Implement Fall Prevention Intervention for At-Risk Resident
Penalty
Summary
Staff failed to consistently implement a fall prevention intervention for a resident with a history of falls and multiple risk factors, including osteoarthritis, muscle weakness, unsteadiness, and cognitive impairment. The resident's care plan specifically required that the walker be kept within reach, following two recent unwitnessed falls where the resident sustained injuries. Despite this intervention being added to the care plan, observations on multiple occasions revealed that the walker was not within the resident's reach—once folded and propped against a bedside table on the opposite side of the bed, and another time placed in the bathroom out of sight. Interviews with staff, including a CNA, LPN, DON, and Rehabilitation Director, confirmed that the walker was not kept within reach as care planned. Staff expressed concerns about the resident's safety if the walker was accessible, given the resident's need for moderate assistance with transfers and ambulation. However, the care plan directive was not followed, and the DON was unaware of staff concerns regarding the intervention. The NHA confirmed the expectation that the walker should be within reach if specified in the care plan.
Failure to Timely Change PICC Line Dressings and Injection Caps
Penalty
Summary
Two residents who had peripherally inserted central catheter (PICC) lines did not receive proper care and treatment as required by their physician orders and facility policy. For one resident with multiple diagnoses including metabolic encephalopathy and endocarditis, the PICC line dressing and injection caps were observed to be dated from the admission date, indicating they had not been changed as ordered. The treatment administration record (TAR) showed the dressing and caps were marked as changed, but direct observation and staff interviews confirmed they were not changed according to the weekly schedule. The Director of Nursing verified that the dressing and injection caps had not been changed as required. Another resident with diagnoses including discitis, spinal stenosis, diabetes, and enterocolitis also had a PICC line with orders for weekly dressing and injection cap changes. The resident reported that these changes were supposed to occur on a specific day each week, but observation revealed the dressing and equipment were not changed on the scheduled day. The TAR indicated the change was completed, but the resident and subsequent observation confirmed the dressing and injection caps were not changed until the following day. Both cases demonstrate a failure to follow physician orders and facility policy regarding the care and maintenance of central lines.
Failure to Follow Enhanced Barrier Precautions for Resident with Wounds
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy for a resident with wounds requiring infection control measures. The policy required all team members to wear appropriate personal protective equipment (PPE), including gown and gloves, during high-contact care activities for residents with chronic wounds. Despite clear signage and a PPE cart at the resident's room, staff were observed providing care and transferring the resident without donning the required PPE. On two separate occasions, certified nursing assistants assisted the resident with peri-care and transferring to bed without wearing gowns or gloves. One CNA was unsure of the resident's EBP status and did not check the posted signage before providing care. The resident's medical record and care plan indicated the presence of chronic wounds and specified the need for EBP, including the use of gown and gloves during care activities. A licensed practical nurse confirmed the resident's wounds and the requirement for EBP. Additionally, a restorative aide admitted to not wearing a gown when re-entering the resident's room to provide assistance, despite being aware of the EBP requirement. The therapy program manager and nursing home administrator both confirmed that staff should follow PPE requirements for residents on EBP. These lapses in infection control practices were directly observed and confirmed through staff interviews and record review.
Failure to Report Verbal Abuse Incident
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically verbal abuse, in accordance with section 1150B of the Act. On November 4, 2024, a Licensed Practical Nurse (LPN-C) was witnessed verbally abusing a resident (R1) in a common area. Despite the facility's policy requiring immediate reporting of such incidents to law enforcement, the verbal abuse was not reported to local authorities. The incident involved LPN-C yelling derogatory terms at R1, who was crying out for help. Multiple staff members, including a Certified Nursing Assistant (CNA-E), a Housekeeper (HK-D), and another LPN (LPN-F), witnessed the incident and noted LPN-C's abnormal behavior, which included yelling, slurred speech, and an unsteady gait, raising concerns about possible intoxication. R1, the resident involved, was receiving hospice services and had diagnoses of dementia, anxiety, and depression, with a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The facility's failure to report the incident to law enforcement was confirmed by the Nursing Home Administrator (NHA-A), who acknowledged the incident as verbal abuse. The facility's policy, revised in September 2024, mandates the reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and law enforcement within specified time frames, which was not adhered to in this case.
Incomplete Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with moderate cognitive impairment, who was receiving hospice services and had diagnoses including dementia, anxiety, and depression. On the morning of the incident, a Licensed Practical Nurse (LPN) was observed verbally abusing the resident in a common area, telling them to stop and calling them a fool. The resident was assisted away from the LPN, who subsequently left the facility and did not return. Although the staff responded to the incident, the investigation was incomplete. The investigation did not include interviews with the resident, other residents, or all staff on duty at the time, including a witness to the incident. Additionally, there was no notification to local law enforcement, and the resident's care plan was not reviewed or revised following the incident. The facility's Nursing Home Administrator indicated that abuse education was not initially provided, as it was considered an isolated incident, and the resident's Power of Attorney for Healthcare had advised against contacting law enforcement due to the resident's dementia. Furthermore, there was no documentation of staff education or notification to the resident's Power of Attorney and physician.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that prescribed medication was available and administered correctly for a resident. The resident had an order for heparin sodium injection to be administered subcutaneously every 8 hours for 14 days. However, the medication was not administered as ordered on several occasions, as indicated by blank spaces on the Medication Administration Record (MAR) and lack of corresponding progress notes. Interviews with the Director of Nursing (DON) and other staff revealed that the facility had heparin available in contingency, and nurses had access to it. Despite this, the medication was not administered at the scheduled times, and there was no documentation to explain the omissions. The DON confirmed that the nurses did not need permission to access contingency medication and that the pharmacy could provide STAT orders if necessary. The investigation also highlighted that the facility's Omnicell machine, which tracks medication usage, did not show any heparin being removed during the relevant period. This suggests that the medication was not administered despite being signed out on the MAR. The DON acknowledged that the medication errors were not identified or reported at the time, and there was no follow-up documentation or incident reports related to the missed doses.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during the provision of incontinence care for a resident. The CNA did not appropriately remove gloves and cleanse hands after providing perineal care. Specifically, the CNA wiped the resident's peri-rectal area with wipes and then proceeded to pull up the resident's clean incontinence brief and pants, assist with ambulation, and touch various items in the resident's room without removing gloves or performing hand hygiene. The CNA's actions were observed by a surveyor, who noted that the CNA touched the resident's gait belt, walker, recliner remote control, blanket, call light, tray table, television remote, bathroom doorknob, and placed a clean nightgown in a dresser drawer, all without removing gloves or cleansing hands. The CNA later removed gloves and left the resident's room without completing hand hygiene. The Director of Nursing confirmed that staff should not double glove and should perform hand hygiene after removing soiled gloves, indicating a failure to adhere to the facility's hand hygiene policy.
Failure to Implement Abuse Policy for Employee Background Checks
Penalty
Summary
The facility did not implement their abuse policy for three of eight employees reviewed for background checks. Specifically, a Registered Nurse (RN) did not have a background check completed within the last four years, and the facility was unable to provide background check information for a Dietary Manager (DM) and a Certified Nursing Assistant (CNA) who were contracted employees. The facility's policy requires pre-employment and other background and abuse registry checks as mandated by local, state, and federal regulations. However, the RN's background information was last updated in 2019, and no updated information was provided. Additionally, the facility failed to provide any background check information for the DM and CNA, both of whom were contracted staff members. The Interim Nursing Home Administrator (INHA) confirmed that the RN's background information was out of compliance, and although a reminder was sent to the RN to complete a new Background Information Disclosure (BID) form, it was not completed. The Nursing Home Administrator (NHA) also confirmed that the facility did not have the required background check information for the DM and CNA. These lapses indicate a failure to adhere to the facility's abuse policy and regulatory requirements for background checks, potentially compromising resident safety and care quality.
Failure to Notify Physician and Monitor Daily Weights
Penalty
Summary
The facility did not ensure appropriate care and treatment for a resident (R2) who experienced a low irregular heart rate and low blood pressure. On 5/1/24, R2's pulse was documented as 50 bpm and irregular, but staff did not notify a physician or take any documented action in response. Similarly, on 5/3/24, R2's blood pressure was recorded as 75/52, and again, no action was taken to notify a physician or address the low blood pressure. R2's family later requested that R2 be seen in the emergency room due to a decline in condition and refusal to eat, leading to R2 being admitted to the ICU for hypotension. The Director of Nursing confirmed that staff should have notified a physician or nurse practitioner of these changes in R2's condition. Additionally, the facility failed to follow physician orders for daily weights for R2, who had diagnoses including congestive heart failure and was at high risk for weight loss and malnutrition. Despite an order for daily weights from admission on 4/29/24, only one weight was documented on 5/3/24. A Registered Dietician assessment on 5/2/24 noted the lack of documented weights and recommended nutritional supplements due to poor appetite. The Director of Nursing verified that staff should have followed the physician's order for daily weights.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility did not ensure staff used a gait belt during transfers for four residents (R4, R5, R6, and R7) out of five sampled residents. R6's baseline care plan indicated the need for assistance with transfers, and the facility's practice was to use a gait belt. However, on 5/29/24, a Certified Nursing Assistant (CNA) transferred R6 from a recliner to a wheelchair without using a gait belt. Additionally, residents R4, R5, and R7 reported that staff did not consistently use a gait belt during transfers. The facility failed to provide a specific transfer policy when requested by the surveyor, only providing a general back safety policy. Observations and interviews revealed that staff did not follow the expected protocol for using gait belts during transfers. R6 was observed being assisted without a gait belt, and interviews with R4, R5, and R7 confirmed that staff often did not use gait belts. The Physical Therapist Assistant (PTA) and Licensed Practical Nurse (LPN) both stated that gait belts should be used for safety during transfers. The Director of Nursing (DON) also confirmed that staff are expected to use gait belts for all assisted transfers. Despite these expectations, the facility did not ensure compliance, leading to the identified deficiency.
Medication Administration Deficiencies
Penalty
Summary
The facility did not ensure the accurate administration of medication for three residents, leading to several deficiencies. One resident, admitted after a fall, had an order for oxycodone for pain management. However, the narcotic count sheet and medication administration record (MAR) did not match, and there was no follow-up documentation for the effectiveness of the medication. Additionally, the facility ran out of the resident's oxycodone, and staff accepted oxycodone brought from the resident's home, which is against the facility's policy. The resident's medical record showed discrepancies in the documentation of administered doses, and the staff involved confirmed the issues during interviews with the surveyor. Another resident, admitted with a history of lung cancer, COPD, and hypertension, did not receive four doses of prescribed medication because the medications were not available upon admission. The resident's medical record indicated that the evening doses of atorvastatin, mirtazapine, Singulair, and guaifenesin were not administered. An agency nurse confirmed that the medications were not delivered on the day of admission and that it was common for new admissions to face such issues. The facility's Director of Nursing (DON) explained the workflow for obtaining medications and acknowledged that agency nurses did not always have access to contingency medication. A third resident, admitted with multiple diagnoses including a transient cerebral ischemic attack and hypertension, did not receive two doses of prescribed medication because the medications were not available upon admission. The resident's MAR indicated that the evening and bedtime doses of pravastatin and Toprol XL were not administered. Interviews with the resident and staff confirmed the issues with medication administration during the initial days of admission. The DON and Assistant Director of Nursing (ADON) provided details about the medication ordering and delivery process, highlighting the challenges faced in ensuring timely medication availability for new admissions.
Improper Administration of Medication
Penalty
Summary
The facility did not ensure that a medication was administered for its intended use for one resident. The resident was prescribed Benadryl as needed for itching but requested and was administered Benadryl for reasons other than itching. The resident, who had intact cognition, was admitted to the facility following a fall and had multiple diagnoses including a fracture, type 2 diabetes, insomnia, and low back pain. On one occasion, the resident reported severe pain and was administered acetaminophen and Benadryl by an agency nurse. The nurse confirmed that the resident requested Benadryl to help sleep, not for itching, and administered it despite the resident not experiencing itching. The facility's Medication Administration policy indicates that medications should be administered for the condition for which they are prescribed. The Assistant Director of Nursing and the Director of Nursing both confirmed that the Benadryl should only have been administered for itching, as per the prescription. The incident highlights a failure to adhere to the prescribed use of medication, leading to the administration of Benadryl for an unapproved reason.
Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse, neglect, or injury to the State Agency (SA) and local law enforcement for five residents. On multiple occasions, residents reported abuse or injuries, but the facility did not submit the required initial reports within the mandated 24-hour period. For instance, Resident 5 and Resident 6 reported abuse on 2/27/24, but the initial reports were not submitted until 3/4/24. Similarly, Resident 7 reported abuse with injury on 3/6/24, but the initial report was delayed until 3/7/24 at 1:48 PM. Resident 3's injury of unknown origin was discovered on 3/28/24, but the initial report was not timely, and the five-day investigation was delayed until 4/4/24. Resident 4 reported abuse on 2/25/24, but the facility failed to notify local law enforcement and delayed the report to the SA until 3/7/24. The facility's policy on Resident Abuse/Neglect/Exploitation and Reporting Requirements mandates that any suspicion of a crime against a resident must be reported to the local law enforcement agency and the state survey agency within specific timeframes. If the incident involves serious bodily injury, it must be reported within 2 hours, and all other incidents must be reported within 24 hours. The results of abuse investigations must be reported to the state survey agency within 5 working days. However, the facility did not adhere to these requirements, leading to delays in reporting and investigation. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that neither had access to the portal to submit Facility-Reported Incidents (FRIs) to the SA until 3/7/24. The DON was unaware of the ability to fax or email concerns, contributing to the delays. The NHA, who started at the facility on 3/4/24, acknowledged the untimely submission of FRIs. These administrative oversights and lack of timely reporting mechanisms resulted in the facility's failure to comply with regulatory requirements for reporting abuse, neglect, and injuries of unknown origin.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were thoroughly investigated for six residents. For two residents, allegations of abuse were reported, but the investigation did not include interviews with other residents or a thorough follow-up on concerns identified through staff interviews. Another resident reported an allegation involving a CNA, but the investigation lacked interviews with staff and other residents, and the CNA was not removed from resident care pending the investigation's outcome. Additionally, a resident had an unwitnessed injury, but the investigation did not summarize or identify the cause of the injury. Another resident reported rough and rude behavior by a CNA, but the investigation did not include interviews with other residents or additional staff, nor did it summarize the investigation or complete staff education. Lastly, a resident reported a serious allegation of sexual assault, but the investigation did not include interviews or assessments of other residents or a summary of the investigation.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility did not ensure that a resident was free from abuse, as evidenced by the failure to implement interventions after staff members voiced concerns regarding a CNA's interactions with residents. On 2/27/24, two residents reported allegations of abuse, and other staff members identified the CNA in question as being rude and unkind. Despite these concerns, the CNA continued to be scheduled for shifts without documented intervention or thorough investigation by the facility. The CNA was later implicated in an incident on 3/5/24, where a resident reported being thrown around in bed, resulting in bruising. The facility's Director of Nursing confirmed that verbal education was provided to the CNA, but no documentation was available to support this claim prior to the incident on 3/5/24. The facility's failure to act on staff concerns and properly investigate the CNA's behavior led to continued exposure of residents to potential abuse. The CNA was eventually terminated on 3/14/24 following the incident on 3/7/24. The report highlights the facility's lack of documentation and thorough investigation, which contributed to the deficiency in protecting residents from abuse.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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