Oak Park Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 718 Jupiter Drive, Madison, Wisconsin 53718
- CMS Provider Number
- 525266
- Inspections on file
- 24
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 40 (3 serious)
Citation history
Health deficiencies cited at Oak Park Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with diabetes, venous insufficiency, neutropenia, obesity, and multiple lower-extremity wounds had physician orders for BID wound care to both feet and legs, bilateral tubi grips for edema, and routine Calmoseptine skin treatment. On one morning shift, the MAR showed these ordered treatments were not administered, and there was no documentation of provision or refusal of care. RNs and the DON confirmed that nurses are responsible for wound care and must sign out completed treatments in the EHR, including refusals, but no additional documentation was available for that shift.
A resident with dementia and other psychiatric diagnoses, who is rarely or never understood per MDS, was observed in a wheelchair with a nitroglycerin patch stuck to the wheelchair wheel, despite having no order for nitroglycerin. An RN confirmed the patch was dated from the prior day and stated that only one other resident on the unit had an order for such a patch, which should have been removed the previous night. Both the RN and the DON described the facility’s required process for nitroglycerin patch disposal—folding the patch in half and placing it in a sharps container or immediately removing it in trash—and acknowledged that the patch found on the wheelchair wheel was not disposed of according to facility policy or accepted professional principles.
The facility failed to implement an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19. Several residents with confirmed respiratory infections, including those with severe cognitive impairment and significant comorbidities, had no physician orders for transmission-based precautions and no care plan interventions addressing their infections. Isolation signage was missing from rooms of infected residents, and visitors entered without performing hand hygiene or using PPE. The IP was absent, and the DON and ADON reported they could not access or interpret the EMR infection tracking system, were not systematically tracking infected or non-infected residents’ respiratory symptoms, and had not entered isolation or droplet precaution orders or related care plans for affected residents. Requested outbreak documentation, including line listings, an outbreak management plan, and ongoing symptom tracking, could not be produced, and EMR infection control records showed the outbreak status and contact tracking had not been updated for several days despite multiple residents and staff reporting respiratory symptoms. These failures resulted in an immediate jeopardy finding under F880 for infection control.
The facility failed to designate and employ a qualified IP and had no trained back-up to manage the infection prevention and control program during an active outbreak of COVID-19, influenza, and RSV. The Regional Nurse identified as the IP had a job description focused on overall operations rather than IP duties, and the DON and ADON, who assumed responsibility in the IP’s absence, reported they were not trained as IPs, lacked access to the EMR infection tracking system, and could not interpret infection data. Outbreak documentation, including line listings, an outbreak management plan, and respiratory symptom tracking for non-infected residents, was not available, and electronic infection tracking had not been updated for several days. A resident with a history of stroke, a resident with Parkinson’s disease, and a resident with atrial fibrillation and a recent fracture developed respiratory symptoms and tested positive for influenza, RSV, or COVID-19, while rooms of infected residents lacked isolation/PPE signage, a visitor entered without hand hygiene or PPE, and housekeeping staff were unaware of the infections or required precautions.
Two residents, one cognitively intact with respiratory and cardiac conditions and one severely cognitively impaired with hypertensive heart disease and generalized anxiety disorder, were subjected to verbally abusive statements by an RN. The intact resident reported that when she requested her ordered narcotic pain medication, the RN called her "addicted," and that she witnessed the RN tell another resident to "stop your damn crying" while administering eye drops. The cognitively impaired resident, for whom the facility is home, could not be interviewed. The facility’s investigation documented these reports but the Administrator later stated he did not believe abuse occurred, despite an existing abuse-prevention policy guaranteeing residents freedom from abuse by staff.
A resident was subjected to verbal abuse by a family member, including yelling, swearing, and the throwing of a hanger, as witnessed and reported by others. Despite these reports, facility staff did not interview the resident, implement protective interventions, report the incident, or conduct an investigation, in violation of the facility's abuse prevention policies.
A resident was subjected to verbal abuse by a family member, witnessed by another resident and a visitor, who reported the incident to Social Services. Despite facility policy requiring immediate reporting of suspected abuse, the allegation was not reported to authorities, and no interventions were implemented to protect the resident.
A resident who was cognitively intact was subjected to verbal abuse by a family member, witnessed by another resident and a visitor. The incident was reported to Social Services and the administrator, but the facility did not conduct a thorough investigation, interview the resident, or implement interventions to ensure safety. The event was not reported to authorities as required by policy.
A resident under Enhanced Barrier Precautions did not receive proper infection control during wound care due to a nurse's failure to secure PPE and perform adequate hand hygiene. The nurse's gown repeatedly fell off, and the resident's foot contacted the nurse's mask and clothing, risking contamination. Interviews revealed gaps in staff training and adherence to infection control protocols.
A resident with intact cognition reported concerns about the cleanliness of her room, which was observed to have dust, debris, and stains on various surfaces, as well as a dark brown spill and spatter that remained unaddressed for several days. The Ancillary Director and facility leadership acknowledged the failure to maintain a clean environment, despite the resident's occasional refusal of chemical cleaners.
The facility failed to create comprehensive care plans for two residents prescribed Melatonin for insomnia, despite lacking a diagnosis of sleep disorders. Both residents received Melatonin daily without proper sleep assessments or evaluations of sleep hygiene. Interviews with staff confirmed the absence of necessary care plans and assessments, leading to the deficiency.
The facility failed to provide consistent and comprehensive wound care assessments for two residents with non-pressure injuries. One resident's wounds were not assessed weekly, and there were discrepancies in wound classification between the facility and external providers. Another resident's new wound was not fully assessed until days later. Technical limitations and inconsistent documentation practices contributed to the deficiency.
The facility failed to provide adequate care and documentation for two residents with pressure injuries. One resident had multiple pressure injuries that were not comprehensively assessed weekly, with inconsistencies in staging between the facility and the Wound Physician. Another resident developed pressure injuries that were misidentified as moisture-associated skin damage, and assessments lacked depth measurements. The facility's failure to follow its policy for weekly assessments and accurate documentation led to inadequate care.
A resident at high risk for falls did not have prescribed safety interventions, such as a low bed and fall mat, in place due to a printing error in the CNA care plan. The CNA was unaware of the resident's fall risk, leading to the absence of necessary precautions until the issue was identified by a surveyor.
Two residents were prescribed antipsychotic medications without appropriate diagnoses or updated consents. One resident received Quetiapine for dementia, and another was given Risperidone for anxiety, both of which are not appropriate indications. Additionally, the consent for an antidepressant was outdated, violating the facility's policy requiring updated consents every 15 months.
Failure to Provide and Document Ordered Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care and skin treatments and to document them according to policy for one resident. The facility’s wound care policy requires documentation of the date and time wound care is given, any refusals and reasons, and the signature and title of the person recording the data. The resident was admitted with multiple significant diagnoses, including type 2 diabetes with diabetic polyneuropathy, neutropenia, venous insufficiency, and obesity, and had multiple wounds on both feet and lower extremities. The physician’s orders included Calmoseptine ointment to the buttocks, groin, and folds every morning and at bedtime and after each toileting episode; bilateral high tubi grips on in the morning and off at bedtime for edema; and multiple specific wound care treatments to the left foot toes, left lower extremity, right foot, and right lower extremity, all to be completed twice daily and as needed. On the morning shift of 1/18/26, the Medication Administration Record showed that these ordered treatments were not administered. There was no documentation that the Calmoseptine, tubi grips, or any of the ordered wound care treatments for the resident’s left foot toes, left lower extremity, right foot, or right lower extremity were provided during that shift. Interviews with multiple RNs and the DON confirmed that nurses are responsible for conducting wound treatments and dressing changes and that, when treatments are completed, they are expected to be signed out in the electronic health record, including documentation if a resident refuses treatment. No further documentation was provided to account for the missing wound care treatments on that morning shift.
Improper Disposal of Nitroglycerin Patch Found on Resident’s Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper disposal of a nitroglycerin transdermal patch in accordance with professional standards and facility policy. During observation in the dining area, a surveyor saw a resident seated in a wheelchair with an oval, paper-tape-like object stuck to the wheelchair wheel. On closer inspection, the object was identified as a nitroglycerin patch labeled with a date of 2/3. Review of the resident’s physician orders confirmed that this resident did not have an order for nitroglycerin. The resident’s diagnoses include dementia, major depressive disorder, and schizophrenia, and the most recent MDS indicated that a BIMS could not be completed because the resident was rarely or never understood. When interviewed, an RN stated that only one resident on the unit had an order for a nitroglycerin patch and that the ordered patch would have been removed the previous night. The RN described the facility’s expected disposal process for nitroglycerin patches as folding the patch in half so the medicated sides adhere together and then placing it in a sharps container or wrapping it in gloves, placing it in the resident’s trash, and immediately removing the trash. The RN acknowledged that the patch found on the wheelchair wheel had not been properly disposed of. The DON similarly stated that nitroglycerin patches should be folded on themselves and placed in a sharps container and agreed that the patch observed on the wheelchair wheel was not properly disposed of, indicating noncompliance with the facility’s medication disposal policy and accepted professional principles.
Failure to Implement Effective Infection Control During Concurrent Influenza, RSV, and COVID Outbreaks
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19, affecting residents, staff, and visitors. The facility did not ensure appropriate physician orders or care plans were in place for multiple residents with confirmed respiratory infections, including influenza, RSV, and COVID. For one resident with a history of stroke and severe cognitive impairment who tested positive for both influenza and RSV, there were no orders addressing management of these infections and no care plan interventions, despite documented respiratory symptoms and positive lab results. This resident’s room lacked any droplet precaution signage, and a visitor entered and exited the room multiple times without performing hand hygiene or using PPE, with staff confirming the absence of signage indicating required precautions. Another resident with Parkinson’s disease and severe cognitive impairment developed respiratory symptoms and later tested positive for influenza. Although a nurse’s note referenced discussion with the NP about Tamiflu and isolation time frames, the comprehensive physician order set contained no orders for transmission-based precautions, and the care plan did not address influenza management. This resident, who had an active order for Tamiflu, also had no droplet precaution signage on the room door. A third resident with dysphagia and a history of sepsis tested positive for influenza, yet had no related physician orders for infection management or TBP and no care plan addressing influenza. A fourth resident, cognitively intact and positive for COVID, had droplet precaution orders in place but no corresponding care plan for COVID management. A fifth resident with vascular dementia and dysphagia tested positive for COVID, but had no droplet precaution orders until several days after symptom onset and no care plan addressing COVID. The facility’s leadership and infection control infrastructure were also deficient. The designated IP was not present in the facility during key survey dates and was unavailable for interview. The DON reported that she and the ADON were responsible for infection control when the IP was absent but stated they could not access or interpret the EMR infection tracking system and had only basic infection control training. The DON acknowledged she was not tracking residents with influenza, RSV, or COVID in an organized manner and was not tracking respiratory symptoms in non-infected residents. She also confirmed that isolation and droplet precaution orders and related care plans had not been entered for residents on droplet precautions for influenza, COVID, and RSV, and that symptom tracking for respiratory illness in all residents had not been occurring prior to a later date. When surveyors repeatedly requested outbreak documentation, including line listings, an outbreak management plan, and evidence of respiratory symptom tracking, the facility could not provide an outbreak management plan or documentation showing systematic tracking of non-infected residents. Infection control documentation from the EMR showed the outbreak status had not been updated for several days, and contact tracking had not been documented beyond its initial entry, despite multiple residents and staff reporting respiratory symptoms during the outbreak. The Administrator and DON were unable to produce an outbreak management plan for the concurrent influenza and COVID outbreaks when interviewed. The DON stated she did not know why droplet precaution signage was missing from the doors of infected residents and reiterated that her expectation was that such signage should be present. A Regional Nurse Consultant confirmed that his expectation for outbreak management included appropriate documentation such as line listings, a functioning outbreak management plan, symptom tracking for staff and residents, and family notification of infection and outbreak status, but the facility lacked this documentation. The combination of missing orders and care plans for infected residents, absent or unclear isolation signage, lack of organized surveillance and tracking, and limited infection control oversight led to the determination of immediate jeopardy related to infection control. The facility’s own policies required prompt identification and management of communicable disease outbreaks, defined thresholds for declaring an outbreak, and assigned responsibilities to the administrator, IP, DON, and staff for surveillance, initiation of transmission-based precautions, and communication with health authorities and families. Policies also required that when residents are placed on transmission-based precautions, appropriate notification be placed on the room entrance door and chart, and that visits to residents on influenza precautions be scheduled and controlled with instruction on hand hygiene and PPE. Despite these written policies, the facility did not implement them during the concurrent outbreaks, as evidenced by the lack of isolation signage, absence of documented TBP orders and care plans for multiple infected residents, and failure to maintain up-to-date outbreak tracking and symptom surveillance. Staff symptom logs provided to surveyors showed multiple employees, including activity aides, housekeepers, CNAs, and an RN, reporting respiratory or flu-like symptoms over several days during the outbreak period. However, there was no evidence that this information was integrated into a broader outbreak management or surveillance system. The EMR infection control management system showed that outbreak status had not been evaluated or updated for several days, and contact tracking documentation had not been continued after its initial entry. These inactions, combined with the absence of a functioning outbreak management plan and the lack of systematic tracking of both infected and non-infected residents, contributed directly to the identified deficiency in the facility’s infection prevention and control program. Overall, the deficiency centers on the facility’s failure to operationalize its infection control policies and CDC-based guidance during simultaneous outbreaks of influenza, RSV, and COVID. This included not ensuring that residents with confirmed infections had appropriate physician orders and individualized care plans, not posting required isolation signage, not maintaining organized surveillance and outbreak tracking, and not having adequately trained and available infection control leadership to manage the situation. These documented failures led surveyors to determine that immediate jeopardy existed under F880 for infection control.
Failure to Designate Qualified Infection Preventionist and Manage Respiratory Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a qualified Infection Preventionist (IP) to develop, implement, and monitor the infection prevention and control program, including during an active outbreak of COVID-19, influenza, and RSV. The facility identified a Regional Nurse as the IP, reportedly working 20 hours per week, but the Regional Nurse’s job description focused on overall facility operations and only generally referenced following established infection control procedures. The facility lacked a qualified back-up IP, and the designated IP was not present in the facility and unavailable for interview during multiple days of the survey while the outbreak was ongoing. During the IP’s absence, the DON and ADON reported they were responsible for managing the infection control program and the current outbreak, but both confirmed they were not trained as IPs, could not interpret the IP’s information, and could not act on her behalf. They also stated they did not have access to the EMR Infection Tracking Program and would not be able to read or understand the information even if they obtained access. The surveyors requested outbreak-related documentation multiple times, including staff and resident line listings, an outbreak management plan, and evidence of respiratory symptom tracking for non-infected residents, but the facility could not provide an outbreak management plan or documentation showing tracking of non-infected residents. Infection control documentation from the facility’s PCC Infection Control Management System showed that outbreak status had not been evaluated, tracked, or updated for several days, and contact tracking documentation had not been updated since the date it was initiated. The deficiency also included specific resident-level findings and infection control lapses. One resident with a history of stroke developed respiratory symptoms and later tested positive for both influenza and RSV, another resident with Parkinson’s disease developed respiratory symptoms and tested positive for influenza, and a third resident with atrial fibrillation and a recent pubic bone fracture developed respiratory symptoms and tested positive for COVID-19. Surveyors observed that required isolation/PPE signage was not posted outside the rooms of residents with RSV and/or influenza. A visitor entered and exited one such resident’s room multiple times without performing hand hygiene or donning PPE, and housekeeping staff reported they were unaware of the residents’ infectious status or required PPE and confirmed there were no signs at the doorways directing them on precautions.
Failure to Protect Residents From Verbal Abuse by RN
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a registered nurse, contrary to its abuse prevention policy that guarantees residents the right to be free from abuse by anyone, including staff. One resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including acute and chronic respiratory failure and heart disease, reported that during the night she requested her ordered narcotic pain medication and the RN responded by referring to her as "addicted." The same resident also reported that on the previous evening she witnessed the RN administering eye drops to another resident and telling that resident to "stop your damn crying" when the resident cried during the procedure. The second resident involved, whose diagnoses included hypertensive heart disease and generalized anxiety disorder and who had a BIMS score of 6 indicating severe cognitive impairment, was described as considering the facility her home and could not be interviewed due to poor cognition. The facility’s own incident reporting and investigation documentation reflected that an investigation into potential verbal abuse of both residents was initiated after the cognitively intact resident reported these events. During a subsequent interview with surveyors, the cognitively intact resident reiterated that she felt verbally abused when called "addicted" and believed the other resident was verbally abused when told to stop her "damn" crying. The Administrator later stated he did not feel either resident was abused and characterized the situation as a "he said/she said" matter, despite the facility’s policy requiring protection from abuse.
Failure to Implement Abuse Prevention Policies Following Family Member's Verbal Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after being made aware that a family member verbally abused a resident—including yelling, swearing, and throwing a hanger in the resident's room—the facility did not take steps to protect the resident from further abuse, did not report the incident, and did not conduct an investigation as required by their abuse prevention policy. Witnesses, including another resident and a visitor, reported the incident to Social Services, describing the family member's behavior as abusive and distressing. Despite these reports, the facility did not interview the resident involved, citing the family member's status as activated power of attorney and their instruction that staff could not speak to the resident without their presence. Staff acknowledged the incident could be considered abuse and confirmed that no interventions or plans were put in place to ensure the resident's safety. The facility also failed to report or thoroughly investigate the allegation, contrary to their own policies and federal requirements.
Failure to Timely Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident and a family member was reported to the appropriate authorities within the required timeframe. On the date of the incident, a family member was observed by another resident and a visitor yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to the facility's Social Services staff, who in turn reported it to the previous Nursing Home Administrator. Despite the facility's policies requiring immediate reporting of suspected abuse to local, state, and federal agencies, the allegation was not reported as required. The resident involved was cognitively intact, as indicated by a recent BIMS score. Staff did not interview the resident about the incident due to instructions from the family member, who was the activated power of attorney, that staff could not speak to the resident without her present. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the facility did not report the allegation to the appropriate agencies as mandated by policy and regulation.
Failure to Investigate and Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported and thoroughly investigated according to state law and facility policy. On 10/22/25, an allegation of verbal abuse by a family member toward a resident was reported to the facility. Witnesses, including another resident and a visitor, described hearing and seeing the family member yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to Social Services, who in turn reported it to the previous Nursing Home Administrator. Despite these reports, the facility did not conduct a thorough investigation, did not interview the resident involved, and did not obtain written witness statements as required by policy. The resident involved was cognitively intact, as indicated by a recent BIMS score of 13. Staff cited the family member's status as activated power of attorney as a reason for not interviewing the resident, stating that the family member required to be present for any staff interaction with the resident. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the incident was not reported to the appropriate authorities as required by federal and state regulations. The facility's inaction was confirmed by both Social Services and the current Nursing Home Administrator during interviews.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) and inadequate hand hygiene practices by a Registered Nurse (RN) during the treatment of a resident. The resident, who was under Enhanced Barrier Precautions due to conditions including Type 2 Diabetes Mellitus with Diabetic Neuropathy and Peripheral Vascular Disease, required specific infection control measures during wound care. However, the RN did not secure the gown properly, leaving it open in the back, and repeatedly allowed it to fall off the shoulders during the procedure, compromising the protective barrier. Throughout the treatment, the RN failed to maintain proper hand hygiene, performing handwashing for significantly less than the recommended 20 seconds. The RN's gown frequently fell off, and at one point, the resident's foot with an old dressing touched the RN's N95 mask, stethoscope, and clothing, leading to potential contamination. Despite these issues, the RN continued the procedure without addressing the gown's fit or the contamination risk. Interviews with the RN and the Director of Nursing (DON) revealed a lack of awareness and adherence to proper infection control protocols. The RN admitted the gown did not fit properly and had not reported this issue to the DON. Additionally, there was a discrepancy in the understanding of the required duration for hand hygiene, with the RN and DON providing incorrect information. These lapses in infection control practices highlight deficiencies in staff training and adherence to established policies, potentially compromising resident safety.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, identified as R31, as evidenced by multiple observations of unclean conditions in her room. R31, who has intact cognition with a BIMS score of 15 out of 15, expressed concerns about the cleanliness of her room. Observations by the surveyor on multiple occasions revealed dust-coated window blinds, debris and stains on window sills, dust on shelving, dried liquid stains on the bedside table, and debris on the floor. Additionally, a dark brown spill and spatter were noted under the bed and on the wall behind the bed, as well as near the door and the dirty linen collection bin. The Ancillary Director acknowledged that the room should have been cleaned more frequently and that the dark brown spill/spatter should have been addressed immediately. It was noted that R31 sometimes refused the use of chemical cleaners, but alternative cleaning methods such as using a dust cloth or soap and water were not employed. The Nursing Home Administrator and Director of Nursing also confirmed that the room should not have remained in such a state for six days and that housekeeping should have been maintaining cleanliness regularly.
Failure to Develop Comprehensive Care Plans for Residents on Melatonin
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents who were prescribed Melatonin for insomnia, despite neither having a diagnosis of insomnia or any other sleep disturbance disorders. Resident 9, with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder, was receiving Melatonin daily without a documented sleep assessment or evaluation of sleep hygiene. Similarly, Resident 42, diagnosed with Alzheimer's disease and dementia, was also receiving Melatonin daily without an up-to-date sleep assessment or evaluation of sleep hygiene. The facility's care plans for both residents lacked documentation regarding the use of Melatonin for insomnia and did not include monitoring of sleep hygiene or the medication's effectiveness. Interviews with facility staff, including the Registered Nurse Unit Manager and the Director of Nursing, revealed an acknowledgment of the deficiency. Both staff members indicated that the residents should have had care plans related to sleep, including monitoring of sleep hygiene and the effectiveness of Melatonin. Additionally, they acknowledged that sleep assessments should be conducted quarterly or at least annually, but these assessments were not completed for the residents in question. The lack of a comprehensive care plan and failure to conduct necessary assessments led to the deficiency identified by the surveyors.
Inconsistent Wound Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services consistent with professional standards of practice, specifically for two residents with non-pressure injuries. One resident, with a history of multiple medical conditions including peripheral vascular disease and chronic osteomyelitis, had several non-pressure injuries that were not comprehensively assessed weekly. The documentation for the location and etiology of these injuries was inconsistent between the facility and the Wound Physician. The facility's records often lacked depth measurements, and there were periods where no weekly assessments were documented. Additionally, there was confusion regarding the classification of wounds as pressure or non-pressure, leading to conflicting documentation between the facility and external wound care providers. Another resident developed a non-pressure injury that was not comprehensively assessed until several days after its initial documentation. The resident, who had a history of diabetes and other significant health issues, was noted to have a new blister and an open area near the rectum, which was not fully assessed until seen by the Wound Physician. The facility's process for wound assessment was hindered by technical limitations, such as a camera system that did not measure wound depth, and there was a lack of manual documentation to compensate for these limitations. The facility's failure to conduct comprehensive and consistent wound assessments, along with discrepancies in wound classification and documentation, contributed to the deficiency. The nursing staff, including a registered nurse who was not wound care certified, did not consistently review or align their documentation with that of the Wound Physician or the wound clinic, leading to ongoing issues in the management and treatment of the residents' wounds.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for two residents with pressure injuries. One resident, identified as R7, had multiple pressure injuries, including a Stage 4 pressure injury to the left heel, a Stage 4 pressure injury to the left lateral foot, and a Stage 3 pressure injury to the left first toe. The facility did not comprehensively assess these wounds weekly, and there were inconsistencies in the documentation of the staging of the pressure injuries between the facility and the Wound Physician. The facility's documentation often lacked depth measurements, and the staging was not accurate according to the Wound Physician's assessments. Another resident, identified as R12, developed a Stage 2 pressure injury to the sacrum, which was not comprehensively assessed until a week later when seen by the Wound Physician. The facility's documentation incorrectly identified the wound as moisture-associated skin damage (MASD) rather than a pressure injury, as documented by the Wound Physician. Additionally, R12 developed a Stage 2 pressure injury to the right thigh, which was also not comprehensively assessed until several days later. The facility's documentation continued to misidentify the etiology of the wounds, and there were no depth measurements recorded. The facility's failure to accurately assess and document the pressure injuries led to a lack of consistent and appropriate care for the residents. The facility's policy required weekly assessments of pressure injuries, but this was not consistently followed. The use of a camera for wound assessments was cited as a reason for missing depth measurements, but manual measurements were not taken when the camera was not functioning. The discrepancies between the facility's documentation and the Wound Physician's assessments contributed to the deficiency in care provided to the residents.
Failure to Implement Fall Risk Interventions for a Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent accidents for a resident identified as R5, who was at high risk for falls. R5 had a history of transient cerebral ischemic attack, essential tremor, and dementia with severe cognitive impairment. The care plan for R5 included interventions such as a low bed and a fall mat to mitigate the risk of falls. However, during an observation, it was noted that these interventions were not in place while R5 was in bed. The bed was not in the lowest position, and the fall mat was not next to the bed, contrary to the care plan requirements. The deficiency was further highlighted when a CNA, responsible for R5's care, was unaware of the fall risk interventions due to a printing error in the CNA care plan sheets. The CNA care plan did not list R5 as a fall risk, leading to the absence of necessary safety measures. Upon inquiry, the CNA found the fall mat in R5's bathroom and placed it next to the bed, and subsequently lowered the bed to the correct position. The RN and RNUM confirmed the oversight, attributing it to a printing error that omitted the fall interventions from the CNA care plan sheets for that day.
Inappropriate Use of Psychotropic Medications and Lack of Consent
Penalty
Summary
The facility failed to ensure that residents using psychotropic drugs had appropriate assessments, diagnoses, and consent, affecting two residents. One resident, identified as R9, was prescribed Quetiapine Fumarate, an antipsychotic, for dementia, which is not an appropriate indication for such medication. This resident was admitted with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder. The facility's policy on psychotropic medication use requires that medications be clinically indicated to treat a specific condition, which was not adhered to in this case. Another resident, R42, was prescribed Risperidone, an antipsychotic, for anxiety, and Citalopram, an antidepressant, without active consent. R42 was admitted with Alzheimer's disease, dementia, and anxiety disorder, but did not have a diagnosis of insomnia or sleep disturbance disorders. The consent for Citalopram was outdated, having been signed over 15 months ago, and the facility's policy requires consents to be updated every 15 months. Interviews with the Registered Nurse Unit Manager and the Director of Nursing confirmed the lack of appropriate diagnosis and consent for the antipsychotic medications prescribed to these residents.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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