North Ridge Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manitowoc, Wisconsin.
- Location
- 1445 N 7th St, Manitowoc, Wisconsin 54220
- CMS Provider Number
- 525389
- Inspections on file
- 35
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at North Ridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions was observed wearing a restraint mitt to prevent pulling on a feeding tube, but there was no physician order, assessment, or care plan documentation for its use. Staff could not identify who applied the mitt, and the facility failed to follow required procedures for restraint use, including documentation of less restrictive alternatives and ongoing evaluation.
The facility failed to administer medications within ordered timeframes for several residents with complex medical needs, and did not consistently complete required narcotic counts at shift changes. Nursing staff administered medications hours after scheduled times and did not document controlled substance counts as required, despite facility policy and prior staff education.
A resident with severe cognitive impairment and a history of exit-seeking behavior eloped from the facility after staff failed to hear and respond promptly to a door alarm. The resident, who was at risk for elopement and equipped with a WanderGuard, was able to leave undetected while staff were providing care in other rooms. The alarm system was not audible in all areas, and staff were unaware of this limitation, resulting in a delayed response and the resident being found two miles away.
Surveyors found that dietary staff did not consistently wear proper hair restraints, maintain kitchen cleanliness, or follow hand hygiene protocols during food preparation and service. Food and beverages were not served at appropriate temperatures, with staff failing to accurately record or monitor food temps. Cleaning logs were incomplete, and resident complaints about food temperature were documented. These deficiencies affected a majority of residents, including those on tube feeding.
A resident with multiple complex medical conditions developed a urinary yeast infection and was prescribed antifungal medication, but the POAHC was not notified of the test results or new treatment. The resident also experienced several episodes of low blood pressure, yet neither the physician nor the POAHC was informed as required by facility policy. Staff interviews and record review confirmed these notification failures.
Staff did not adhere to infection control protocols for two residents, including one on contact precautions for C. diff and another requiring incontinence care. Multiple staff entered a resident's room and provided care without donning required PPE, despite being aware of the need for contact precautions. In a separate incident, a CNA failed to perform hand hygiene between glove changes and did not provide thorough perineal care during incontinence care, contrary to facility policy. These deficiencies were confirmed through direct observation and staff interviews.
The facility failed to obtain necessary guardianship and protective placement orders for three residents and did not honor a resident's advance directive against nursing home placement. The social worker confirmed the lack of a process to ensure proper documentation, and the nursing home administrator acknowledged the oversight in admitting a resident against their stated wishes.
Surveyors found that medication carts were left unlocked and unattended, exposing residents' health information. Expired medications and supplies were also discovered in medication carts and storage rooms. Staff confirmed these deficiencies, acknowledging that night shift nurses should monitor for expired items.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 33 residents. Observations included unclean kitchen equipment, improper hand hygiene by a cook, and lack of food holding temperature documentation. Additionally, food items were found without discard dates or past their discard dates, indicating non-compliance with FDA Food Code standards.
The facility failed to maintain effective infection control practices, with staff not adhering to hand hygiene and PPE protocols. An APNP did not change gloves during wound care, and staff failed to wear masks in COVID-19 affected areas. A PT did not wear a gown during therapy with a resident on EBP. An LPN did not perform hand hygiene during medication administration. These actions indicate significant deficiencies in infection prevention.
The facility did not ensure that residents were assessed for safe self-administration of medication. An LPN and an RN left medications with residents without physician orders, assessments, or care plans. One resident had intact cognition, another had moderate cognitive impairment, and a third was responsible for their healthcare decisions, yet none had the necessary documentation for self-administration.
A resident with hemiplegia and hemiparesis had their call light out of reach, contrary to their care plan and facility policy. Despite previous grievances and staff education, the issue persisted, highlighting a deficiency in ensuring call light accessibility.
A resident's medical record lacked a Power of Attorney for Healthcare (POAHC) document upon admission, despite having intact cognition and being admitted with serious health conditions. The facility's policy requires advance directives to be documented upon admission, but this was not done. Attempts to obtain the POAHC from the resident's spouse were sporadic and only completed after surveyor intervention, highlighting a lapse in the facility's process.
The facility failed to provide proper written transfer notifications to three residents and their representatives, as required by policy. Verbal authorizations were obtained without the necessary written documentation or signatures. The social worker responsible confirmed the oversight, leading to the deficiency.
The facility failed to provide written bed hold policy notifications to three residents or their representatives during hospital transfers. Despite obtaining verbal authorizations, the facility did not ensure that written notices were signed or documented in the residents' medical records, as required by their Transfer and Discharge policy.
A resident with severe cognitive impairment and a history of pressure injuries did not receive necessary care to prevent new ulcers. Observations revealed the resident's feet were in direct contact with the mattress without required heel boots, and dressings were not changed as ordered. Staff interviews highlighted inconsistencies in following the care plan and physician orders, leading to a deficiency in pressure ulcer care.
A resident with emphysema and COPD, known to smoke, did not receive required quarterly smoking assessments as per the facility's policy. Despite being educated on smoking procedures, the facility failed to conduct assessments in 9/2023, 12/2023, and 3/2024, as confirmed by the DON. This oversight was identified during a survey, highlighting a lapse in maintaining a hazard-free environment.
A facility failed to consistently document and communicate vital signs and weights for a resident undergoing dialysis, as required by their policy. The resident, with end-stage renal disease and CHF, had multiple instances of missing documentation in their medical record and dialysis communication binder. The DON and an RN confirmed these lapses, which were against physician orders and facility policy.
The facility failed to complete and follow up on monthly medication reviews for two residents, resulting in deficiencies. One resident's PRN lorazepam recommendation was delayed by 122 days, and another resident's self-administration assessment for nebulizer treatment was not conducted. Both residents had severe cognitive impairments, and the facility did not act on pharmacist recommendations promptly.
The facility inaccurately submitted staffing data to CMS for fiscal quarters 1 and 2 of 2024, indicating low weekend staffing. This was due to a new payroll system that failed to include salaried employees working weekends. The issue was not detected initially, and the facility had not addressed the reporting inaccuracies before the surveyor's inquiry.
The facility failed to serve pasta salad at a safe temperature, with measurements ranging from 52.5 to 61.7 degrees Fahrenheit, exceeding the safe limit of 41 degrees. Despite being aware of the discrepancy, the kitchen staff did not take immediate corrective action. The Dietary Manager confirmed the facility's adherence to the Wisconsin Food Code and noted that the pasta salad is usually prepared a day in advance to ensure proper cooling, which was not done in this instance.
The facility was found deficient in maintaining sanitary food handling practices, with staff failing to perform proper hand hygiene before donning gloves and touching ready-to-eat food with bare hands. Additionally, unsanitary garbage disposal practices were observed, as staff manually handled garbage can lids after washing hands. These actions were contrary to the Wisconsin Food Code and the facility's hand hygiene policy.
A resident with a history of stroke, chronic respiratory failure, and CHF experienced increased lethargy and low oxygen saturation. The facility failed to document complete assessments or notify the physician promptly, as required by policy. Interviews revealed delays in notifying the provider and incomplete documentation of the resident's condition and care.
The facility failed to monitor weights for two residents with PEG tubes as per physician orders. One resident, with moderate cognitive impairment, missed 48 of 91 daily weights, while another resident, with intact cognition, missed 6 of 11 weekly weights. Staff interviews confirmed the discrepancies in weight monitoring.
A facility failed to prepare and serve pureed diet meals according to the recipe and extended menu for a resident with dysphagia. The cook did not measure chicken broth or serving sizes, and the dietary manager confirmed that the kitchen staff lacked access to updated recipes and serving sizes since a menu change. The resident was on a pureed diet and received tube feeding.
The facility failed to serve milk at a safe and appetizing temperature, with a test tray showing milk at 53.6 degrees Fahrenheit, above the guideline of 41 degrees Fahrenheit or below. The Dietary Manager confirmed the milk was too warm and suggested it was not iced down enough.
A cook was observed preparing coffee cake batter without consistently performing hand hygiene, including touching the storage door's electronic lock and door handle and then returning to food preparation without washing hands. The Dietary Manager confirmed that the cook should have washed hands before continuing to mix the batter.
Failure to Assess, Document, and Care Plan for Use of Physical Restraint Mitt
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson's disease, stroke history, COPD, dysphagia, hemiplegia, and schizophrenia, was observed wearing a restraint mitt on the left hand. The facility's policy requires a documented medical symptom, assessment, physician order, and care plan interventions before the use of any physical restraint. However, the resident's medical record lacked any restraint assessment, physician order, or care plan documentation related to the restraint mitt. Staff interviews confirmed the mitt was used to prevent the resident from pulling on a feeding tube, but none could identify who applied it or provide evidence of required documentation or assessment. The resident's care plan did not address the use of the restraint mitt, and there was no documentation of less restrictive alternatives being attempted or ongoing re-evaluation of the restraint's necessity. The Director of Nursing and Nurse Practitioner both confirmed the absence of an order or care plan for the mitt, and the mitt's use was not mentioned in the resident's recent hospital discharge summary. The facility failed to follow its own policy and federal requirements regarding the use of physical restraints, resulting in the imposition of a restraint without proper assessment, documentation, or care planning.
Medication Administration and Narcotic Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure the accurate administration of medications for four residents, as well as consistent reconciliation of narcotic medications. Surveyors observed that medications for several residents were not administered within the timeframes specified by physician orders and facility policy. For example, one resident with diagnoses including congestive heart failure and chronic pain received furosemide at times significantly later than the ordered administration times, with documentation showing doses given hours after the scheduled times. Another resident with chronic respiratory failure and dependence on a ventilator received multiple medications, all scheduled for early morning administration, several hours late. Similar late administration was observed for two additional residents, both with complex medical histories and scheduled medication times that were not adhered to by nursing staff. Interviews with staff revealed that the nurse responsible for administering morning medications typically began the process after the scheduled time and completed it several hours later, often due to responding to ventilator alarms and other duties. The Director of Nursing confirmed that nurses were allowed up to two hours after the scheduled administration time to give medications, but the observed delays exceeded this window. Residents and staff interviews corroborated that medications were frequently administered outside of the prescribed timeframes, contrary to facility policy and physician orders. Additionally, the facility did not consistently complete required controlled substance counts at shift changes. Review of the Controlled Substance Record Books for multiple wings showed numerous missing signatures for various shifts over a period of several weeks, indicating that narcotic counts were not being verified and documented as required. Staff interviews confirmed that both the outgoing and incoming nurses were responsible for this process, and that it should occur at every shift change. Despite prior education on this requirement, documentation showed ongoing noncompliance with controlled substance reconciliation.
Failure to Provide Adequate Supervision Results in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and severe cognitive impairment was not provided with adequate supervision, resulting in the resident leaving the facility undetected. The resident had diagnoses including paranoid schizophrenia, epilepsy, panic disorder, anxiety, and depression, and was assessed as being at risk for elopement. The care plan indicated the use of a WanderGuard device and noted the resident's frequent exit-seeking behaviors and moderate fall risk. Despite these interventions, the resident was able to exit the facility through a door equipped with an alarm. On the night of the incident, staff were providing care in residents' rooms and did not hear the door alarm when it was triggered. Multiple staff members confirmed during interviews that the door and WanderGuard alarms were difficult or impossible to hear while inside resident rooms with the doors closed. The alarm was not responded to until several minutes after the resident had already left the facility. The resident was eventually found approximately two miles away, having traversed busy streets and intersections, and was returned to the facility. The facility's policy required staff to be vigilant and respond to alarms in a timely manner, emphasizing that alarms are not a substitute for necessary supervision. However, staff were unaware that the alarm system could not be heard in certain areas, and there was no process in place to ensure alarms were audible throughout the building. Documentation also showed gaps in required 15-minute checks for the resident after the incident. The failure to provide adequate supervision and to respond promptly to the alarm led to the resident's elopement and constituted a finding of immediate jeopardy.
Deficient Food Safety and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, as evidenced by multiple observations and staff interviews. Staff did not consistently wear hair restraints that fully covered their hair and facial hair while preparing and serving food, despite facility policy and posted signage requiring full coverage. Specific staff members were observed with exposed hair and beards during meal preparation and service, and staff acknowledged that hair and facial hair should be fully covered at all times in the kitchen. Kitchen equipment and food service areas were not maintained in a clean and sanitary condition. The kitchen floors and shelves in the cook, prep, and serve areas were observed to be dirty and contained debris. Review of cleaning logs revealed that daily cleaning tasks were frequently not completed or documented, with a significant number of assigned tasks left unsigned over several weeks. The Director of Dining confirmed that staff were expected to complete cleaning assignments daily, but this was not occurring as required. Hand hygiene practices were not followed appropriately by staff during food preparation and service. Staff were observed touching food and food-contact surfaces with bare hands, wiping hands on clothing, adjusting glasses, and changing gloves without performing hand hygiene in between. Additionally, food and beverages were not consistently served at appropriate temperatures. Staff failed to obtain and record actual food temperatures during meal service, instead recording fabricated or estimated temperatures on logs. Test trays revealed that most hot and cold foods and beverages were not within the required temperature ranges, and resident grievances and council meeting minutes documented ongoing complaints about improper food temperatures.
Failure to Notify Resident Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to ensure that a resident's Power of Attorney for Healthcare (POAHC) was notified of significant changes in the resident's condition and treatment. The resident, who had diagnoses including quadriplegia, diabetes mellitus type 2, and a stage 4 sacral pressure ulcer, was found to have yeast in the urine and was prescribed an antifungal medication. Although the POAHC was informed that a urinalysis and urine culture would be performed, there was no documentation that the POAHC was notified of the test results or the initiation of antifungal treatment. The POAHC confirmed not being informed about the results or the new medication order, only learning of further developments when the resident was transferred to the hospital after becoming unresponsive. Additionally, the resident experienced multiple episodes of low blood pressure over two consecutive days. The facility's policy and standing orders required that the physician and the resident's representative be notified of such significant changes, especially when blood pressure readings fell below specified thresholds. However, there was no evidence in the medical record that either the physician or the POAHC was notified of these low blood pressure readings. Interviews with facility staff confirmed that these notifications did not occur, and staff acknowledged that such notifications should have been made. The facility's own policy, revised shortly before the incident, required prompt notification of the resident, physician, and representative in the event of significant changes in condition or treatment. Despite this, documentation and interviews revealed that the required notifications were not consistently made or documented, particularly regarding the new infection, treatment, and episodes of low blood pressure. The deficiency was identified through record review and interviews with the POAHC and facility staff.
Failure to Follow Infection Control Protocols for Residents on Contact Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols for two residents with significant medical needs. One resident, who had a history of malignant neoplasm of the glottis, COPD, chronic respiratory failure, and a tracheostomy, was on contact precautions due to a Clostridioides difficile (C. diff) infection. Despite clear signage indicating contact precautions, multiple staff members, including two CNAs and an RN, entered the resident's room and provided direct care without donning the required personal protective equipment (PPE) such as gowns and gloves. Both the CNAs and the RN acknowledged after the fact that they were aware of the contact precautions and should have worn PPE while in the room. Another resident, with diagnoses including myotonic muscular dystrophy, chronic respiratory failure, encephalopathy, and heart failure, required assistance with toileting and personal hygiene. During an observed episode of incontinence care, a CNA and an LPN donned PPE before entering the room and transferred the resident using a full body lift. However, the CNA did not perform hand hygiene between glove changes, did not cleanse the resident's entire perineal area after a soiled brief was removed, and failed to change gloves before applying barrier cream. The CNA also continued to perform tasks such as changing the resident's gown and cleaning equipment without completing hand hygiene between glove changes, contrary to facility policy. Interviews with staff, including the CNA, LPN, DON, and the Nursing Home Administrator, confirmed that the observed actions did not align with the facility's policies on hand hygiene, perineal care, and transmission-based precautions. The facility's policies require staff to perform hand hygiene before and after glove use, cleanse the entire perineal area during care, and don appropriate PPE for residents on contact precautions. These lapses in infection control practices were directly observed and acknowledged by staff during interviews.
Failure to Obtain Guardianship Orders and Honor Advance Directives
Penalty
Summary
The facility failed to ensure that guardianship and protective placement orders were obtained and advance directive wishes were followed for four residents. Resident 31 had a legal guardian at the time of admission, but their medical record did not contain the necessary guardianship or protective placement orders. Similarly, Resident 43's medical record lacked these orders despite having a legal guardian and a scheduled hearing. Resident 39 also had a legal guardian, but their medical record was missing current protective placement orders. The facility's social worker confirmed that there was no process in place to ensure the documentation of guardianship and protective placement orders in residents' medical records. Resident 30 had completed a Power of Attorney for Healthcare (POAHC) indicating a preference against nursing home placement. Despite this, Resident 30 was admitted to the facility. The social worker verified that the POAHC paperwork was marked 'No' for nursing home placement and acknowledged that the resident should not have been admitted based on their stated wishes. The business office staff and nursing home administrator also confirmed that the facility would typically review such documentation and not admit a resident if they had indicated 'No' to nursing home admission. The deficiencies highlight a lack of proper documentation and adherence to residents' legal and advance directive wishes. The facility did not have a process to ensure that guardianship and protective placement paperwork was obtained and documented, leading to non-compliance with state statutes. Additionally, the facility failed to honor a resident's advance directive, resulting in an admission that contradicted the resident's expressed wishes.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with its policy, as observed by surveyors. Three out of four medication carts were found unlocked and unattended on multiple occasions across different wings of the facility. This included instances where a computer screen displaying residents' health information was left exposed. Staff members, including registered nurses, confirmed that medication carts should be locked when unattended, but admitted to forgetting to do so. Additionally, expired medications and medical supplies were found in two of the medication carts and one of the medication storage rooms. Items such as syringes, eye ointments, and various medications were past their expiration dates. Licensed Practical Nurses verified these findings and acknowledged that night shift nurses were responsible for monitoring the medication carts and storage rooms for expired items. The Director of Nursing confirmed the presence of expired medications and supplies and stated that expiration dates should be checked when loading medication carts.
Sanitation and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect 33 of the 47 residents. During an initial kitchen tour, the surveyor observed dust, dried food debris, and unidentified substances on storage bins of utensils, a broken bin exposing utensils to air, and food debris on preparation surfaces. Additionally, an open bag of sausage links was found on soiled scissors and tinfoil, and dried food debris was noted inside a microwave. The Dietary Manager (DM) acknowledged that cleaning tasks were assigned but not logged or signed off by staff. Hand hygiene practices were also found to be inadequate. A cook was observed preparing lunch without changing gloves or performing hand hygiene despite touching various surfaces and food items. The cook admitted to not knowing the frequency of hand hygiene education, while the DM confirmed that staff were expected to perform hand hygiene after leaving the trayline or touching contaminated surfaces. The DM acknowledged concerns about the cook's hand hygiene during meal service. Furthermore, the facility did not document food holding temperatures unless an audit was being conducted. The DM stated that temperatures were only checked while food was cooking, not during holding. Additionally, several food items in the reach-in cooler and resident refrigerator were found without discard dates or were past their discard dates, including pitchers of lemonade and pre-thickened cranberry juice. These observations indicate a lack of adherence to the FDA Food Code regarding food storage and handling practices.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and personal protective equipment (PPE) usage. During wound care for a resident with a stage 3 coccyx pressure injury, an Advanced Practice Nurse Prescriber (APNP) did not change gloves or perform hand hygiene after handling soiled dressings and before touching clean items. This was confirmed by the Director of Nursing (DON), who acknowledged the breach in protocol. Additionally, staff failed to adhere to mask-wearing protocols in areas with a COVID-19 positive resident. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) were observed not wearing masks or wearing them improperly while interacting with residents. The DON confirmed that masks should be worn at all times in these areas. Furthermore, during a therapy session with a resident on Enhanced Barrier Precautions (EBP) for carbapenem-resistant Acinetobacter baumannii, a Physical Therapist (PT) did not wear a gown as required, which was verified by both the PT and the DON. The report also highlights several instances of improper hand hygiene during medication administration. A Licensed Practical Nurse (LPN) was observed not performing hand hygiene before and after preparing medications for multiple residents. The DON confirmed that hand hygiene should be completed before medication preparation, after preparation, and after administration. These repeated failures to follow established infection control protocols indicate significant deficiencies in the facility's infection prevention and control practices.
Failure to Assess Residents for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that three residents were assessed as able to safely and accurately self-administer medication. On the specified date, an LPN left medication with a resident for self-administration without a physician's order, self-administration assessment, or care plan indicating the resident could safely do so. This resident had intact cognition and was responsible for their healthcare decisions, yet the necessary documentation and assessments were absent. Similarly, another resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare was left with medication at their bedside without the required physician's order, assessment, or care plan. Additionally, a third resident with intact cognition was provided with a nebulizer solution to self-administer without the necessary documentation or assessment. The Director of Nursing confirmed the lack of appropriate orders, assessments, and care plans for these residents, indicating a systemic issue in the facility's adherence to its self-administration of medication policy.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by the resident's care plan. The resident, who was admitted with conditions including hemiplegia and hemiparesis following a cerebral infarction, had a care plan intervention specifically stating that the call light should be within reach due to their risk of falls and other health issues. Despite this, during an observation, the call light was found attached to the bed rail and not accessible to the resident, who confirmed they could not reach it. The facility's policy on call light accessibility was not adhered to, as evidenced by the resident's grievance filed a month prior, which highlighted the same issue of the call light being out of reach after transfers. Although the facility had taken steps to address the grievance by updating the care plan, posting reminders, and educating staff, the deficiency persisted. This was confirmed during an interview with the Director of Nursing, who acknowledged that call lights should be within reach for all residents.
Failure to Document Advance Directives for a Resident
Penalty
Summary
The facility failed to ensure that the medical record contained advance directives for a resident, identified as R13, among the 17 sampled residents. R13 was admitted with diagnoses including congestive heart failure and pulmonary embolism, and had a BIMS score indicating intact cognition. Despite this, R13's medical record did not contain a Power of Attorney for Healthcare (POAHC) document upon admission. The facility's policy requires that advance directives be determined and documented upon admission, but this was not adhered to in R13's case. Interviews and record reviews revealed that the facility did not have R13's POAHC paperwork until after the surveyor's request. The social worker had been in communication with R13's spouse, who had difficulty locating the paperwork. Documentation showed sporadic attempts to obtain the POAHC over a period of years, but the paperwork was only completed and scanned into the medical record after the surveyor's intervention. The facility's staff, including the Nursing Home Administrator and Social Worker, were unable to confirm if the timeframe for obtaining the POAHC was reasonable, indicating a lapse in the facility's process for handling advance directives.
Failure to Provide Proper Transfer Notifications
Penalty
Summary
The facility failed to provide proper notification of transfer or discharge to three residents and their representatives, as required by their policy. Resident 12 was transferred to the hospital due to hypotension and increased lethargy, but the activated Power of Attorney for Healthcare did not receive a written transfer notice. Similarly, Resident 23 was transferred due to paralysis without receiving a written transfer notice, and Resident 31, who was transferred multiple times for various medical reasons, did not have their court-appointed guardian receive written transfer notices. The facility's policy mandates that transfer/discharge notices include information about appeal rights and contact details for the State Long-Term Care Ombudsman, and be provided in a language and manner understandable to the resident and their representative. However, the surveyor's review revealed that verbal transfer authorizations were obtained without the necessary written documentation or signatures from the residents or their representatives. The social worker responsible for ensuring these notices were provided confirmed that the required documentation was not completed, leading to the deficiency.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written notifications of the bed hold policy to three residents or their representatives during hospital transfers. Resident 12 was transferred to the hospital due to hypotension and increased lethargy, but neither the resident nor their Power of Attorney for Healthcare (POAHC) received a written notice of the bed hold policy. Similarly, Resident 23, who was transferred due to paralysis, did not receive a written notice, and the resident confirmed not signing or receiving such a notice. Resident 31 experienced multiple hospital transfers for various medical issues, including abnormal lung sounds and seizure activity, yet neither the resident nor their court-appointed guardian received written notices of the bed hold policy. The facility's Transfer and Discharge policy requires that a notice of transfer and the bed hold policy be provided to residents and their representatives. However, the surveyor's review revealed that the medical records for Residents 12, 23, and 31 lacked documentation of these notices. Although verbal authorizations were obtained, the written notices were not signed by the residents or their representatives, and the Social Worker responsible for ensuring the distribution of these notices confirmed the oversight. This deficiency highlights a failure in the facility's process to ensure compliance with its own policy regarding bed hold notifications.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to ensure that a resident with multiple healed pressure and deep tissue injuries received the necessary care and services to promote healing and prevent new pressure injuries. The resident, who had severe cognitive impairment and a history of pressure injuries, was observed without the required heel boots and pressure-relieving devices, contrary to the care plan and physician orders. The resident's care plan included interventions such as a hip abductor pillow, a pillow between the lower legs, and soft heel boots to prevent pressure injuries. During observations, the surveyor noted that the resident's feet, ankles, and heels were in direct contact with the mattress, and the resident was not wearing heel boots as required. The dressings on the resident's left lateral foot and ankle were dated several days prior, indicating they had not been changed according to the prescribed schedule. The Treatment Administration Record (TAR) showed that the dressings were marked as changed, but the nurse responsible could not recall completing the wound care. Interviews with staff, including a CNA, an APNP, an RN, and the Director of Nursing, revealed inconsistencies in the implementation of the resident's wound care orders. The RN acknowledged that the dressings should have been changed more frequently, and the DON confirmed the expectation for staff to follow physician orders and document care accurately. The failure to adhere to the care plan and physician orders resulted in a deficiency in providing appropriate pressure ulcer care for the resident.
Failure to Conduct Quarterly Smoking Assessments
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not conducting quarterly smoking assessments for a resident known to smoke cigarettes. The facility's Smoking Safety policy requires smoking assessments to be completed upon admission, quarterly, and as needed. However, the resident, who was admitted on 6/2/23 and had diagnoses including emphysema and COPD, did not receive the required quarterly assessments in 9/2023, 12/2023, and 3/2024. This oversight was confirmed by the Director of Nursing, who acknowledged that the assessments were not completed as per the facility's policy. The resident, who had a BIMS score indicating intact cognition, was assessed as an unsupervised smoker, with the facility storing their lighter and cigarettes. Despite being educated on the facility's smoking procedure, the lack of timely assessments represents a failure to adhere to the established policy, potentially compromising the safety of the resident and the facility. The deficiency was identified during a survey conducted from 8/12/24 to 8/14/24, where it was confirmed that the necessary education to ensure timely smoking assessments was not initiated.
Inconsistent Documentation of Dialysis Care
Penalty
Summary
The facility failed to ensure consistent documentation and communication of vital signs and weights for a resident receiving dialysis, leading to a deficiency in care. The resident, who was diagnosed with end-stage renal disease and congestive heart failure, required dialysis three times a week. The facility's policy mandated that vital signs and weights be recorded and communicated to the dialysis facility before and after each session. However, the surveyor found multiple instances where this documentation was missing from the resident's medical record and dialysis communication binder. The Director of Nursing and a Registered Nurse confirmed the lapses in documentation, acknowledging that the required pre- and post-dialysis vital signs and weights were not consistently recorded. Specific dates were identified where the resident's pre-dialysis weight, post-dialysis weight, and vital signs were not documented, indicating a failure to adhere to physician orders and facility policy. This lack of documentation and communication could potentially impact the resident's care and treatment outcomes.
Deficiencies in Medication Review and Follow-Up
Penalty
Summary
The facility failed to ensure that monthly medication reviews were completed and followed up on for two residents, leading to deficiencies in medication management. One resident, who was admitted with diagnoses including anoxic brain injury and anxiety, had a pharmacy recommendation from October 2023 to discontinue or create a new order for PRN lorazepam, as PRN psychotropic medication orders cannot exceed 14 days without documented rationale and duration. This recommendation was not addressed until February 2024, 122 days later, during which time the resident was administered lorazepam multiple times. Additionally, there was no documented medication review for this resident in March 2024, despite the resident being present in the facility for most of the month. Another resident, also with severe cognitive impairment, had a pharmacy recommendation from November 2023 to conduct a self-administration assessment for nebulizer treatment. This assessment was not completed, and the resident's ability to self-administer the medication was not documented. The Director of Nursing confirmed the lack of follow-up on these recommendations, indicating a failure in the facility's process to act on pharmacist recommendations in a timely manner.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to ensure the accurate submission of mandatory staffing information to the Centers for Medicare & Medicaid Services (CMS) based on payroll data. This deficiency was identified during a survey when the Payroll Based Journal (PBJ) data for fiscal quarters 1 and 2 of 2024 indicated excessively low weekend staffing. Upon review, it was found that the staff ratios were appropriate according to the Facility Assessment, suggesting that the data submitted to CMS was inaccurate. The Nursing Home Administrator (NHA) and Administrator In Training (AIT) confirmed that the data was not submitted correctly, as the facility had not noticed the issue due to a new payroll system introduced in October 2023. The problem arose because salaried employees, such as the Director of Nursing (DON), who worked on weekends, were not automatically included in the PBJ data submission. This issue was not detected by the facility initially, as no salaried employees worked weekends during the first quarter. The Corporate Business Office Manager (CBOM) was responsible for submitting the staffing data, but there was a lack of communication and follow-up with the surveyor regarding the inaccuracies. The facility had not begun working on a plan to address the system issue for accurate reporting to CMS before the surveyor's inquiry.
Improper Temperature Control of Pasta Salad
Penalty
Summary
The facility failed to ensure that pasta salad was served at a safe and appetizing temperature, as required by the Wisconsin Food Code and the facility's own Food Preparation Guidelines. On the specified date, a surveyor observed kitchen staff preparing and serving a mayonnaise-based cold pasta salad at temperatures significantly above the safe limit of 41 degrees Fahrenheit. The pasta salad was measured at temperatures ranging from 52.5 to 61.7 degrees Fahrenheit, which is above the recommended cold holding temperature. The kitchen staff member responsible for preparing the pasta salad acknowledged the temperature discrepancy but did not take immediate corrective action due to being too busy. The Dietary Manager confirmed that the facility follows the Wisconsin Food Code and that the pasta salad should have been cooled to 41 degrees Fahrenheit or lower before serving. The Dietary Manager also noted that the pasta salad is typically prepared the day before and cooled overnight, but on this occasion, it was made on the same day. Despite previous education on food temperatures, the staff failed to adhere to the facility's food temperature logs and did not check the temperatures before serving. The Nursing Home Administrator expressed an expectation for kitchen staff to follow the established policies for food preparation and serving.
Improper Hand Hygiene and Unsanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, as observed during a survey. Multiple instances of improper hand hygiene were noted among the kitchen staff, which included not washing hands before donning gloves, touching ready-to-eat food with bare hands, and handling garbage without subsequent handwashing. Specifically, a cook was seen placing lids on bowls of pasta salad with bare hands, and a dietary aide did the same with residents' drinks. Additionally, the dietary manager was observed picking up an item from the floor, disposing of it in the garbage, and then putting on gloves without washing hands. The kitchen's garbage disposal practices were also found to be unsanitary. The garbage can in use required manual handling to open, which led to staff touching the lid with bare hands after washing. This practice was acknowledged by the dietary manager and other staff as unsanitary. The dietary manager admitted to being nervous and forgetting proper hand hygiene protocols, despite recent training. The facility's failure to adhere to the Wisconsin Food Code and its own hand hygiene policy was evident, as staff sometimes left garbage on a cart instead of disposing of it properly.
Failure to Document and Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident who experienced a change in condition. On the specified date, the resident, who had a history of nontraumatic intracranial hemorrhage, chronic respiratory failure, and congestive heart failure, showed increased lethargy and low oxygen saturation levels. Despite these changes, the staff did not document complete and accurate assessments or notify the resident's physician in a timely manner, as required by the facility's Notification of Changes policy. The resident's medical record indicated that a new medication, trazodone, was administered the evening before the change in condition. On the day of the incident, a registered nurse noted the resident's decline but failed to document all vital signs and assessments conducted. The nurse contacted the nurse practitioner twice, but the documentation was incomplete, and there was a delay in notifying the physician about the resident's condition. Interviews with the Director of Nursing and the Medical Director revealed that the facility did not adhere to the expected protocol of immediate notification of the provider when the resident's condition changed. The Medical Director confirmed that the facility's calls to the medical group's on-call service were delayed, and orders for further evaluation were not promptly executed. The Nursing Home Administrator acknowledged the concerns related to the delay in care and documentation issues.
Failure to Monitor Weights for Residents with PEG Tubes
Penalty
Summary
The facility failed to ensure that two residents with percutaneous endoscopic gastrostomy (PEG) tubes received appropriate treatment and services to prevent adverse consequences of enteral feeding. Resident R10, who had moderate cognitive impairment and was not responsible for their healthcare decisions, had a care plan that required daily weight monitoring due to nutritional problems related to various medical conditions. However, R10's Treatment Administration Record (TAR) showed that 48 out of 91 ordered daily weights were missing. Interviews with the Registered Nurse (RN) and the Director of Nursing (DON) confirmed the missing weights and the lack of adherence to the physician's orders. Similarly, Resident R11, who had intact cognition and was responsible for their healthcare decisions, had a care plan that required weekly weight monitoring due to swallowing difficulties and a mechanically altered diet. Despite the order for weekly weights on bath days, R11's TAR indicated that 6 out of 11 weekly weights were not obtained. Interviews with the RN, Certified Nursing Assistant (CNA), and DON verified the missing weights and the failure to follow the prescribed weight monitoring schedule.
Failure to Follow Pureed Diet Recipe and Serving Sizes
Penalty
Summary
The facility failed to ensure that menu items were prepared according to the recipe and served according to the extended menu for a resident on a pureed diet. During a lunch service, the staff did not follow the pureed food recipe and did not use an appropriate serving size for pureed chicken. The cook added chicken broth to baked chicken in a food processor without measuring the broth, and then served the pureed chicken mixture without measuring the serving size. The dietary manager confirmed that the staff should measure the chicken stock to maintain nutritional value and follow portion sizes on the menu. The resident involved had a diagnosis of dysphagia and was on a pureed diet, also receiving nutrition via tube feeding. The dietary manager admitted that the kitchen staff did not have access to pureed diet recipes and serving sizes since the menu was changed, as the book containing these details was not updated. The cook verified not following the recipe and used an unmeasured amount of chicken broth instead of mayonnaise as per the recipe. The extended menu indicated a serving size of 1/3 cup for the pureed chicken sandwich, which was not adhered to.
Milk Served at Unsafe Temperature
Penalty
Summary
The facility did not ensure that milk was served at a safe and appetizing temperature, as observed during a survey. On the specified date, the temperature of milk served on a test tray was recorded at 53.6 degrees Fahrenheit, which is above the facility's guideline of 41 degrees Fahrenheit or below for cold foods. The surveyor observed the kitchen staff preparing room trays for the lunch meal and noted that the milk's temperature was initially 42.8 degrees Fahrenheit when taken from a deep tray containing ice. However, during the delivery process, the meal cart door was left open at times, and the last meal tray was delivered at 12:12 PM. By the time the temperature of the milk on the test tray was checked again at 12:14 PM, it had risen to 53.6 degrees Fahrenheit. The cook acknowledged that the milk was too warm. The Dietary Manager confirmed that milk should be served between 32 and 40 degrees Fahrenheit unless residents request it warmer. Upon reviewing the observation, the Dietary Manager verified that the milk was too warm and suggested that it might not have been iced down enough that day. This deficiency had the potential to affect multiple residents in the facility, excluding those who received nutrition via enteral feeding.
Inadequate Hand Hygiene During Food Preparation
Penalty
Summary
The facility did not ensure staff performed appropriate hand hygiene during food preparation, which had the potential to affect multiple residents. On 5/20/24, a cook was observed preparing coffee cake batter without consistently performing hand hygiene. The cook mixed the batter with a whisk and bare hands, left the food preparation area, touched the storage door's electronic lock and door handle, and then returned to food preparation without washing hands. The cook continued mixing the batter and poured it into a pan before finally washing hands after turning on the oven. The Dietary Manager confirmed that kitchen staff are expected to wash their hands before returning to food preparation after leaving the area. The manager verified that the cook should have washed hands after touching the electronic lock and door handle and before continuing to mix the cake batter. This failure to follow proper hand hygiene protocols was observed and documented by the surveyor.
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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