Oak Park Place Of Janesville
Inspection history, citations, penalties and survey trends for this long-term care facility in Janesville, Wisconsin.
- Location
- 700 Myrtle Way, Janesville, Wisconsin 53545
- CMS Provider Number
- 525728
- Inspections on file
- 20
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Oak Park Place Of Janesville during CMS and state inspections, most recent first.
The facility failed to follow its grievance policy and document investigation and resolution efforts after a resident’s AHCPOA emailed the NHA with multiple care concerns, including dirty clothing, poor hygiene, an untreated red eye needing more frequent drops, lack of snacks and fluids despite the resident calling out for something to drink, and missing eyeglasses and hearing aids. Although facility policy requires grievances to be documented on forms, routed to the grievance official, logged, investigated, and concluded with a written decision, no grievance entry or related documentation was found. The NHA reported treating these repeated concerns as routine day-to-day care issues rather than formal grievances and acknowledged not completing the required grievance documentation or investigation.
Surveyors observed staff entering kitchen and kitchenette areas without required hairnets during food preparation and service, and found multiple food safety violations including unlabeled, expired, and uncovered food items, a dented can in circulation, and incomplete temperature monitoring of refrigeration units. There was also confusion among staff regarding responsibility for cleaning and monitoring food storage areas, with no clear policy in place.
Surveyors found that multiple residents were routinely served meals using plastic silverware and Styrofoam cups, both in their rooms and in the dining room, despite available supplies of regular dishware. Several cognitively intact residents expressed difficulty and dissatisfaction with the use of disposables, and staff interviews revealed inconsistent practices and a lack of clear procedures for ensuring adequate regular utensils and cups were provided, resulting in a failure to uphold residents' dignity during meals.
Several residents were found living in unclean and uncomfortable rooms, with unmade beds, overflowing trash, debris, and soiled items left unattended. Staff and residents confirmed the lack of regular cleaning, and housekeeping staff reported no consistent cleaning schedule or documentation. These conditions persisted despite facility policy requiring regular cleaning and immediate attention to visibly soiled areas.
A resident with paraplegia, anxiety disorder, PTSD, and depression, who was cognitively intact and his own decision maker, did not have a documented discharge care plan or care conference. The facility's policy requires resident participation in care planning, but interviews and record review confirmed that discharge planning was not discussed or documented for this resident.
Two residents with indwelling catheters did not receive appropriate care: one had a catheter placed without a documented diagnosis or care plan, and another's catheter bag was left uncovered and visible from the hallway, contrary to the care plan. The DON and CNA confirmed these lapses in catheter management and privacy.
A resident with PTSD did not receive a complete trauma assessment or have a care plan addressing their trauma history, triggers, or interventions. The social worker confirmed that the assessment was incomplete and the care plan did not address the resident's PTSD, resulting in a failure to provide trauma-informed, culturally competent care.
Surveyors found an open multi-dose Tuberculin vial in the medication room refrigerator that lacked both an open date and expiration date, in violation of facility policy. An RN confirmed the vial should have been dated and that all staff share responsibility for labeling. The DON was unaware of the issue and mistakenly believed the vials were single-use, but the pharmacy confirmed they were multi-dose.
A resident with multiple diagnoses, including heart failure, was admitted while already receiving hospice services, but the facility failed to maintain required hospice documentation and did not have a coordinated hospice care plan in the EHR. Staff interviews revealed inconsistent processes for obtaining and storing hospice records, and hospice documentation was only provided after surveyor intervention.
Staff failed to follow infection control protocols for two residents requiring transmission-based precautions. An LPN entered the room of a COVID-19 positive resident without any PPE, despite clear signage and policy requirements. In a separate incident, a nurse performed tracheostomy care for another resident without wearing a gown and did not perform hand hygiene between glove changes, contrary to enhanced barrier precautions and facility policy. Leadership confirmed that proper PPE and hand hygiene were required in both cases.
The facility did not conduct thorough investigations into multiple allegations of abuse, neglect, and mistreatment, including a case of injury of unknown origin, reports of rough care and neglect, and a verbal altercation involving a family member. Investigations lacked key documentation such as staff and resident interviews, skin assessments, and evidence of staff education, with facility leadership acknowledging incomplete records and missing documentation.
A facility failed to monitor a resident's diuretic medication and provide necessary supplements, resulting in hospitalization due to critically low blood levels. Additionally, the facility did not consistently document weights for two residents as ordered by physicians, increasing health risks. Staff interviews revealed issues with processing orders and documentation, contributing to these deficiencies.
The facility failed to provide sufficient nurse staffing, leading to delayed response times to call lights and unmet resident needs. Despite the facility's assessment indicating specific staffing requirements, the schedule showed significant gaps, with missing RNs or LPNs and CNAs not showing up for work. Residents and family members reported long waits for assistance, and staff acknowledged being overwhelmed with tasks, indicating inadequate staffing to meet resident needs.
A facility failed to document and communicate necessary information during a resident's hospital transfer. The resident, with T-cell lymphoma and other conditions, was transferred due to worsening health. The transfer form lacked critical details about the resident's condition and necessary documents, which was acknowledged by the Regional Clinical Nurse.
A facility failed to provide ADLs according to the care plan for a resident with adult failure to thrive, resulting in an unkempt appearance and lack of documented showers. Staff interviews revealed confusion about shower schedules and inadequate documentation of care refusals, while the ADON confirmed the resident's appearance and the need for family involvement in providing clothing.
A resident with multiple wounds, including a stage 3 pressure ulcer and a scalp burn, was not consistently assessed or monitored by the facility. The resident refused wound care multiple times, but the provider was not notified as required by the facility's policy. Additionally, there was a discrepancy in the wound care provided, with Medi-honey being used instead of the prescribed Silvadene. The Regional Clinical Nurse confirmed that the assessment and monitoring of the wounds were not conducted, leading to a deficiency in care.
A resident with Parkinson's disease and dementia did not receive his Trazadone medication at the preferred time, as specified in his physician's orders. The medication was administered late on two occasions, once by an agency nurse unfamiliar with the resident's needs. The Regional Clinical Nurse confirmed the timing error, and the resident's family member reported the issue to the Regional Nurse.
The facility failed to maintain complete and accurate medical records for two residents, leading to potential unmet care needs. One resident with T-cell Lymphoma and skin issues had undocumented skin/wound assessments over several days, while another resident with colon cancer and pressure ulcers had incomplete daily charting. The ADON acknowledged the documentation lapses, which should have been recorded daily.
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, affecting all 12 residents. Staff did not follow policies on hair restraints, dishwashing, thermometer sanitization, hand washing, and food labeling. Chef Q and other staff were observed not practicing proper hand hygiene and glove use, and undated food items were found in multiple locations. Residents R2 and R4 were directly affected by these deficiencies.
The facility failed to ensure accurate PBJ reporting, resulting in deficiencies for not maintaining 24-hour licensed nursing coverage and RN hours on multiple dates across two fiscal year quarters. The NHA provided documentation to prove compliance, but the CASPER Report did not reflect this.
The facility failed to maintain an effective infection prevention and control program, allowing staff to return to work too soon after reporting symptoms and not documenting symptom onset accurately. Additionally, a CNA performed catheter care on a resident without appropriate hand hygiene, handling clean and dirty items interchangeably.
The facility failed to ensure that five residents received necessary services for good nutrition, grooming, personal, and oral hygiene. Residents did not receive scheduled showers, and one resident was left without food and utensils during mealtime. This was contrary to the facility's policy and care plans.
The facility failed to provide an ongoing program of activities designed to meet the interests and well-being of residents. Care plans were not person-centered, and activity programming was inadequate, affecting seven residents. Staff acknowledged the need for individualized care plans but failed to implement them effectively.
The facility failed to ensure residents were treated with dignity and respect, affecting three residents in the dining area. One resident waited 29 minutes for assistance with his meal while having an uncovered catheter bag, uncombed hair, and an unshaven face. Another resident's catheter bag was uncovered despite her preference for it to be covered. A third resident with moderate cognitive impairment also had an uncovered catheter bag. Staff acknowledged the need for dignity bags but did not consistently use them.
A resident suggested an intervention for pain management during a care plan conference, but the facility failed to include it in her care plan. As a result, the resident experienced increased pain and reduced mobility. The social worker did not update the care plan or inform the staff, and the Director of Nursing acknowledged the oversight.
The facility failed to follow professional standards for hand hygiene and did not include specific interventions in the care plan for a resident with a stage 3 pressure injury. Improper hand hygiene was observed during wound care, and contaminated supplies were used. The baseline care plan lacked detailed interventions to promote healing or prevent worsening of the pressure injury.
The facility failed to provide appropriate catheter care and infection control for two residents. One resident's catheter was observed dragging on the floor, and another resident's catheter made contact with the floor multiple times during an adjustment. The DON confirmed that such practices are against infection control protocols.
A facility failed to ensure proper monitoring and emergency interventions for a resident with a dialysis fistula. The resident's care plan and MAR/TAR lacked necessary entries for monitoring the fistula, and staff were not adequately trained on emergency procedures for bleeding from the fistula.
A resident admitted with multiple health conditions was not weighed according to the facility's Weight Management policy, which required daily and weekly weigh-ins. The resident expressed concern about losing seven pounds since admission, and the Director of Nursing acknowledged the failure to follow weight orders, leading to a deficiency.
A resident with severe cognitive impairment and a history of multiple falls experienced eight falls within ten days. The facility failed to implement effective fall interventions and provide adequate supervision, resulting in a displaced right inferior pubic ramus fracture. Contradictory care plan interventions and the absence of a toileting schedule contributed to the deficiency.
Failure to Follow and Document Grievance Process for Resident Care Concerns
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to document grievances and prompt efforts to resolve them for a resident whose Activated Health Care Power of Attorney (AHCPOA) raised multiple concerns. The facility’s Grievance Program policy dated 5/15/24 states that grievances, defined as formal written or verbal complaints when prompt bedside resolution is not possible, must be documented on Comment/Concern Forms, routed to the grievance official, listed on the tracking log, discussed as warranted, and investigated accordingly. The policy also requires written grievance decisions to include dates, a summary of the grievance, corrective actions, and the date the written decision was issued to the complainant. The resident was admitted with diagnoses including cerebral infarction without residual effects and dysarthria/anarthria, and was on hospice services upon admission. Surveyors reviewed email communications from the AHCPOA to the Nursing Home Administrator (NHA) that listed specific concerns about the resident’s care, including the resident wearing dirty clothes, a full laundry bag, an unclean or unshaven face, a very red right eye needing more frequent eye drops, being found sitting unattended in the dining room while calling out for something to drink, lack of a mid-morning snack, difficulty obtaining coffee or juice, no juice cups in the room, eyeglasses found in the trash, and absence of hearing aids. When surveyors reviewed the facility’s grievance log, no grievance entry for this resident was found. In an interview, the NHA stated that when a grievance comes to her, she typically initiates a grievance form, works through what is needed, and follows up with the resident or family. However, regarding these concerns, the NHA acknowledged that due to the repetitive nature of the issues, she considered them part of day-to-day care rather than grievances, did not complete a grievance form, and had no documentation of investigation, follow-up, or resolution for the concerns raised, despite recognizing that she should have done so. As a result, the facility did not follow its grievance process.
Failure to Maintain Food Safety Standards and Proper Food Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations and interviews. Staff, including the Regional Maintenance Director and the Director of Nursing, were observed entering the main kitchen and kitchenette areas without wearing required hairnets, despite facility policy mandating hair restraints when working with food. During meal service, food was being prepared and served while staff were not in compliance with hair restraint policies. Surveyors found food items that had been removed from their original containers and were not labeled with use-by dates, as well as a dented can of jellied cranberry sauce in circulation. In the kitchenette freezer and refrigerator, there were uncovered and unlabeled food items, including opened containers of ice cream and sundae cups with ice crystals, as well as expired and undated food. The refrigerator and freezer temperature logs were incomplete, with several days missing recorded temperatures, and there was no clear assignment of responsibility for monitoring these temperatures. Additionally, the kitchenette cupboards contained unwrapped candy, dried substances, opened and expired food items, and food without proper labeling. Interviews with dietary, nursing, and housekeeping staff revealed confusion and lack of clarity regarding who was responsible for cleaning and monitoring the kitchenette areas, with no established policy or procedure in place for these tasks. These deficiencies had the potential to affect nearly all residents in the facility.
Failure to Provide Dignified Dining Experience Due to Use of Disposable Utensils and Cups
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect during meal service, as required by federal and state regulations. Multiple observations revealed that residents, both in their rooms and in the main dining room, were consistently provided with plastic silverware and Styrofoam cups instead of regular metal utensils and glassware. This practice was noted to affect several residents, including those who were cognitively intact and able to express their preferences. Residents reported difficulty using plastic utensils to cut food and expressed a preference for regular silverware and cups, indicating that the use of disposables negatively impacted their dining experience. Interviews with staff, including CNAs, the Dietary Manager, and the Director of Nursing, revealed inconsistent knowledge and practices regarding the use of disposable versus regular dishware. Some staff stated that they used disposable items when regular supplies ran out, while others were unaware of the reason for using disposables. The Dietary Manager indicated that there was an adequate supply of regular dishware and utensils, and backup supplies were available, but staff did not always access them. The process for ensuring enough regular dishware and utensils were available for all residents was not clearly defined or consistently followed. The facility's policy on resident rights, which emphasizes the right to a dignified existence and respectful treatment, was not upheld in these instances. The lack of regular dishware and utensils, despite available supplies, led to residents being served meals in a manner that did not promote dignity or an enhanced quality of life. The deficiency was substantiated by direct observations, resident interviews, and staff statements, all indicating a systemic issue with the provision of appropriate dining materials.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
Multiple residents were found to be living in rooms that were not maintained in a safe, clean, comfortable, and homelike manner, as required by facility policy. Surveyors observed unmade beds, overflowing trash cans, dust bunnies, debris, and soiled items such as used gloves and adult incontinence products left on the floor. In several cases, residents' bathrooms were also found to be unclean, with dried stool on toilet seats and trash bags left on the floor. These conditions were confirmed by both staff and residents, who acknowledged that the rooms were not clean or homelike. Interviews with staff, including CNAs, housekeepers, and the Nursing Home Administrator, revealed a lack of a consistent cleaning schedule and inadequate documentation of when rooms were cleaned. Housekeeping staff reported that room cleaning frequency depended on staffing levels and workload, with some rooms not being cleaned for several days. Residents reported having to request cleaning, with some stating their rooms had not been cleaned since admission or that spills and debris remained for extended periods. One resident expressed embarrassment over the state of her room, especially when having visitors. The facility's own policy required regular cleaning of housekeeping surfaces and immediate cleaning when surfaces were visibly soiled. However, observations and interviews indicated that this policy was not being followed. The lack of a structured cleaning schedule and documentation system contributed to the ongoing unclean conditions in multiple residents' rooms, directly impacting their right to a safe and homelike environment.
Failure to Develop and Document Discharge Plan for Resident
Penalty
Summary
A deficiency was identified when the facility failed to develop a discharge plan for one of three residents reviewed for discharge planning. The facility's policy requires that each resident's comprehensive care plan be consistent with their rights to participate in the development and implementation of their care, including establishing goals and outcomes. The resident in question was admitted with diagnoses including paraplegia, anxiety disorder, PTSD, and recurrent depressive disorders, and was found to be cognitively intact and his own decision maker. Despite these factors, there was no documentation of a care conference or a discharge care plan in the resident's medical record. During interviews, the resident confirmed that no one had discussed discharge planning with him and that he had not participated in a care conference. The social worker explained that the usual process involves setting up a care conference within 5-7 days of admission and another meeting 1-2 weeks later to address equipment and support needs, with documentation under the assessments tab. However, upon review, both the surveyor and the social worker confirmed that there was no documentation of a care conference or discharge care plan for this resident, indicating a failure to follow the facility's established discharge planning process.
Failure to Provide Appropriate Catheter Care and Privacy
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, as evidenced by two specific cases. In the first case, a resident with moderate cognitive impairment and multiple diagnoses, including anxiety disorder, major depressive disorder, and heart failure, had an indwelling catheter placed without an appropriate supporting diagnosis. The resident's physician order indicated the catheter was for hospice/comfort, but there was no documented care plan addressing the catheter, and the Director of Nursing was unable to immediately provide the rationale or documentation for its use beyond referencing hospice notes. In the second case, another resident with a Foley catheter had a care plan specifying that the catheter bag and tubing should be positioned below the bladder and away from the entrance room door or covered for privacy. However, the catheter bag was observed hanging on the bed frame, facing the door, and visible from the hallway without a cover. The CNA responsible for the resident's care confirmed that the bag was not covered or repositioned as required, and the Director of Nursing acknowledged that the care plan interventions were not followed.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD. Upon review, it was found that the resident, who has a history of paraplegia, anxiety disorder, PTSD, and recurrent depressive disorders, did not have a complete trauma assessment or a care plan addressing their PTSD diagnosis, triggers, or specific interventions. The resident's most recent MDS indicated cognitive intactness and some social isolation, but the care plan lacked any reference to PTSD or trauma-related needs. Further investigation revealed that the trauma history evaluation for the resident was only partially completed, with only two out of six sections fully filled out. During an interview, the facility's social worker confirmed that the process for residents with PTSD should include a complete trauma assessment and a care plan addressing trauma, triggers, and interventions. However, the social worker acknowledged that these steps were not completed for this resident, resulting in a deficiency in providing care that is trauma-informed and culturally competent as required by facility policy.
Failure to Label Multi-Dose Tuberculin Vial in Medication Room
Penalty
Summary
Surveyors observed that the facility failed to ensure all drugs and biologicals were properly labeled in accordance with professional standards. Specifically, an open vial of Tuberculin solution was found in the medication room refrigerator without an open date or expiration date, contrary to the facility's policy requiring multi-dose vials to be dated and discarded within 28 days unless otherwise specified by the manufacturer. During interviews, a registered nurse confirmed that the vial should have been dated and acknowledged that it should be discarded if not properly labeled, stating that responsibility for dating medications is shared among staff. The Director of Nursing was unaware of the issue and believed the vials were single-use, but the facility’s pharmacy confirmed that all Tuberculin vials provided are multi-dose.
Failure to Maintain and Coordinate Hospice Documentation and Care Plan
Penalty
Summary
The facility failed to ensure that a resident receiving hospice services had appropriate hospice documentation and a coordinated care plan in accordance with professional standards of practice. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and acute on chronic heart failure, was admitted to the facility already enrolled in hospice. Despite this, the facility did not have documentation of the resident's hospice enrollment, admission assessment, care plan, orders, or visit notes in the electronic health record. Additionally, there was no facility-generated care plan addressing hospice for the resident prior to the surveyor's inquiry. Interviews with facility staff revealed inconsistent processes for obtaining and storing hospice documentation. The RN stated that hospice care plans and visit notes should be faxed and scanned into the EHR, but only one hospice note was found, and no care plan was available. The DON indicated that hospice documentation should be available in binders on the unit, but was only able to provide the required documents after the surveyor's request. The hospice nurse confirmed that routine visit notes were not regularly faxed to the facility and that the care plan and visit notes were only sent after a recent request. This lack of timely and accessible hospice documentation resulted in the facility not meeting its policy requirements for coordinated care for residents on hospice.
Failure to Maintain Infection Control Precautions for Residents on Isolation and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple breaches in transmission-based precautions for two residents. In one instance, a resident with a confirmed diagnosis of COVID-19 was placed on droplet precautions, with appropriate signage and PPE supplies available outside the room. However, a Licensed Practical Nurse (LPN) was observed entering the resident's room without wearing any required personal protective equipment, including a mask, gown, gloves, or eye protection, despite being aware of the resident's COVID-19 status and the need for such precautions. Both the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who also serves as the infection preventionist, confirmed that proper PPE should have been used in this situation. In another case, a resident with a tracheostomy was under enhanced barrier precautions, as indicated by signage and a PPE cart outside the room. During tracheostomy care, a Registered Nurse (RN) performed hand hygiene initially but then set up care supplies with bare hands and failed to don a gown, as required. The RN removed and replaced gloves multiple times during the procedure without performing hand hygiene between glove changes, only doing so at the end of the care. The RN acknowledged not following proper hand hygiene protocols and not wearing a gown, both of which were required by facility policy for this type of care. Interviews with the ADON confirmed that hand hygiene should have been performed after each glove removal and that enhanced barrier precautions, including the use of gown and gloves, were necessary for tracheostomy care. The facility's own policies, as well as physician orders, outlined these requirements, but staff failed to adhere to them during the observed care activities.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to ensure thorough investigations of alleged abuse, neglect, and mistreatment for four out of five residents reviewed. In one case, a resident with severe cognitive impairment was found to have labial bruising and vaginal tears of unknown origin while hospitalized. The facility's investigation did not address discrepancies in transportation times, did not include all relevant staff interviews, and failed to conduct or document comprehensive skin assessments for all residents following the incident. Additionally, the investigation lacked documentation of education or competency checks for transport drivers and did not include interviews with contracted hospice nurses. Another resident, who was cognitively intact, reported not receiving pain medication and assistance despite repeated requests, leading to distress and a grievance report. The facility's documentation did not include interviews with other residents about missed care, education provided to staff, or records of follow-up support. The investigation file was incomplete, and key documentation such as staff interviews and education records could not be located by facility leadership. Additional deficiencies were noted in the handling of a resident's report of neglect and rough care, as well as a verbal altercation between a resident and a family member. In both cases, the facility failed to document thorough investigations, including interviews with involved parties, skin assessments, and staff education. Facility leadership acknowledged during interviews that the investigations were incomplete and lacked supporting documentation, failing to meet the requirements outlined in the facility's own abuse prevention policies.
Failure to Monitor Medication and Document Weights Leads to Resident Harm
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice for three residents, leading to significant health complications. Resident R3, who was admitted with congestive heart failure, was prescribed Furosemide, a diuretic known to cause potassium and sodium depletion. Despite this, the facility did not monitor R3's electrolyte levels or provide potassium supplementation, resulting in critically low sodium and potassium levels and subsequent hospitalization. Additionally, the facility did not discontinue Furosemide as ordered upon R3's readmission, further exacerbating the resident's condition. The facility also failed to consistently monitor and document the weights of residents R1 and R3 as per physician orders. R3's daily weights were not recorded on numerous occasions, which was crucial for managing his heart failure condition. Similarly, R1 missed several scheduled weight checks, which were part of the physician's orders to monitor the resident's health status. These lapses in documentation and monitoring increased the risk of health complications for the residents. Interviews with facility staff revealed systemic issues in the handling of physician orders and documentation. The Assistant Director of Nursing admitted to personal issues affecting the processing of transfer orders, leading to medication errors. The Director of Nursing acknowledged that while CNAs were responsible for taking weights, the nurses often failed to document them in the electronic medical record. These failures in communication and documentation contributed to the deficiencies observed in the care of the residents.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nurse staffing to meet the needs of its residents, compromising their safety and well-being. The facility's assessment indicated a need for specific staffing levels based on resident acuity and census, including one Nurse Manager on the first shift, one RN/LPN on each shift, and one to three CNAs on the first and second shifts. However, the staffing schedule from January 9 to January 11 revealed significant gaps, with instances of missing RNs or LPNs on shifts and CNAs not showing up for work, leading to understaffed shifts. Interviews with residents and family members highlighted the impact of inadequate staffing, with reports of delayed response times to call lights and residents experiencing incontinence due to long waits for assistance. One resident, who was cognitively intact, reported a 22-minute wait for help to use the bathroom. Family members expressed concerns about insufficient staff, particularly during evening and night shifts, resulting in unmet needs and prolonged wait times for assistance. Staff interviews corroborated these concerns, with CNAs and other staff members acknowledging the challenges of managing resident care with insufficient staffing. They reported being overwhelmed with tasks such as answering call lights, providing showers, and ensuring residents were fed. The Assistant Director of Nursing and other staff members agreed that the facility was not adequately staffed to meet the residents' needs, despite the facility's claim of exceeding state minimum requirements. The Regional Clinical Nurse noted that staff were not being utilized effectively, further contributing to the deficiency.
Incomplete Documentation and Communication During Resident Transfer
Penalty
Summary
The facility failed to properly document and communicate necessary information during the transfer of a resident to a hospital. The resident, who was admitted with T-cell lymphoma, skin cancer, and diabetes, was transferred due to generalized weakness, failure to thrive, and worsening skin condition. The physician recommended hospital transfer for diagnostic and lab testing, with a potential helicopter transfer to Rochester, MN for further care. However, the transfer documentation was incomplete, lacking critical information about the resident's condition, including respiratory status, skin/wound care, and rehabilitation therapy. Additionally, the transfer form did not include essential documents such as a face sheet, personal belongings list, current medication list, advanced directives, recent medical history, and relevant x-ray results. The Regional Clinical Nurse acknowledged that the transfer form was not fully completed, which was against the facility's expectations. This oversight in documentation and communication could have impacted the continuity of care for the resident during the hospital transfer.
Failure to Provide ADLs According to Care Plan
Penalty
Summary
The facility failed to provide activities of daily living (ADLs) according to the care plan for a resident (R5) who was admitted with diagnoses including adult failure to thrive and a need for personal care. The care plan indicated that R5 required extensive assistance for bathing and dressing, and limited assistance for personal hygiene. However, observations revealed that R5 was not receiving the necessary care, as evidenced by her unkempt appearance, including greasy hair, long chin and lip hair, and wearing the same clothes over consecutive days. The facility's records showed no documented showers for R5 since her admission, and interviews with staff indicated a lack of clarity and communication regarding the provision of showers and personal care. Interviews with the CNA and OT revealed that R5 had refused some personal care activities, such as sponge baths, but there was no documentation of these refusals in the point of care (POC) system. The CNA admitted to not providing a shower to R5 and was unaware of the protocol for addressing the lack of clothing or notifying the family. The Assistant Director of Nursing (ADON) confirmed the observations of R5's appearance and acknowledged the need for family involvement in providing additional clothing. The Director of Nursing (DON) highlighted issues with staff documentation practices, emphasizing the need for accurate recording of care refusals.
Failure to Monitor and Communicate Wound Care for Resident
Penalty
Summary
The facility failed to consistently assess and monitor pressure ulcers and wounds for a resident, identified as R4, who was admitted with multiple wounds, including a stage 3 pressure ulcer, a deep-tissue injury, and a scalp burn. Upon admission, the facility's documentation did not include measurements or assessments of R4's wounds, and there was a lack of timely wound evaluation, as the Director of Nursing only assessed the wounds six days after admission. Additionally, the facility did not document any updates to the provider regarding the resident's wounds. R4 refused wound care on multiple occasions, stating that dressings did not need to be changed if they were not bleeding. Despite the resident's refusal, there was no documentation indicating that the provider was notified of these refusals. The facility's policy required notification of the supervisor and provider when a resident refused wound care, but this was not adhered to in R4's case. Furthermore, there was an inconsistency in the wound care provided, as Medi-honey was applied to the scalp wound instead of the prescribed Silvadene. The facility's failure to document and communicate effectively about R4's wound care and refusals resulted in a lack of proper monitoring and assessment. The Regional Clinical Nurse confirmed that the assessment and monitoring of the wounds were not conducted, and the provider was not informed of the resident's refusal to have wound care performed. This lack of adherence to the facility's wound care policy and procedures contributed to the deficiency identified in the report.
Medication Timing Error for Resident with Parkinson's
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R6, who did not receive his Trazadone medication according to his preference and physician's orders. R6, who was admitted with diagnoses including a left leg fracture, Parkinson's disease, and dementia, had a BIMS score indicating he was cognitively intact. His physician's orders specified that Trazadone, an antidepressant, should be administered at 6:00 PM, with a special precaution to give the medication between 6:30 PM and 7:00 PM due to his preference to go to bed around 7:00 PM. On two occasions, R6's medication was administered late. On one occasion, the medication was given after 7:30 PM, and on another, it was administered at 7:15 PM by an agency nurse unfamiliar with the resident's needs. This delay in medication administration was confirmed by the Regional Clinical Nurse, who acknowledged that the medications were not given according to the special precautions banner. The resident's family member, FM1, expressed concerns about the timing of the medication and reported these issues to the Regional Nurse, who provided his contact information for further issues.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, R1 and R4, which placed them at risk of unmet care needs. For R1, who was admitted with diagnoses including T-cell Lymphoma, skin cancer, and diabetes, the facility did not document skin/wound assessments in the daily Medicare and/or Skilled Charting documentation from 11/14/24 to 11/18/24. Despite having a stage four pressure ulcer on the sacrum, an unstageable pressure ulcer on the scrotum, and a deep-tissue injury on the heels, there was no documentation in the Nursing Progress Notes regarding these conditions. The Assistant Director of Nursing (ADON) acknowledged the lack of documentation and stated that any out-of-the-ordinary conditions should have been recorded. Similarly, for R4, who was admitted with colon cancer, stage 3 ulcers, and diabetes, the facility failed to complete the required daily Medicare and/or Skilled Charting documentation on several occasions, including 12/25/24, 12/30/24, 01/04/25, 01/05/25, and 01/09/25. R4 had a stage 3 pressure ulcer, a deep-tissue injury, and was receiving intravenous antibiotic therapy for a wound infection. The ADON confirmed that the Medicare and/or Skilled Charting documentation should be completed daily and updated with any new issues the resident develops.
Deficiencies in Food Safety and Hand Hygiene
Penalty
Summary
The facility did not maintain a safe and sanitary environment for food preparation, storage, and distribution, affecting all 12 residents. Staff were observed working in the kitchen without beard nets, contrary to the facility's policy. Chef Q was seen placing dirty pans in a rack and then handling clean pans without washing his hands or wearing gloves, and the metal pans were wet stacked on a drying rack. Additionally, the thermometer probe was not sanitized between temping resident food, and Chef Q was observed putting garbage and gloves in the garbage can without washing his hands before returning to cooking. KM P was also observed dishing up lunch with gloves on, making a phone call, and then returning to the steam table with the same gloves on. Undated food items were found in the cook's refrigerator and the first-floor kitchenette, and Lead Activity Assistant E served lunch to residents with soiled gloves on, touching various surfaces without washing hands or changing gloves. The facility's policies on hair restraints, dishwashing, thermometer sanitization, hand washing, and food labeling and dating were not followed. Chef Q and DA R were observed preparing food without beard nets, and Chef Q did not follow proper hand hygiene and glove use when handling dirty and clean dishes. The thermometer probe was not disinfected between uses, and Chef Q did not wash his hands after handling garbage. KM P did not change gloves or wash hands after making a phone call before continuing to dish up lunch. Undated food items were found in multiple locations, and Lead Activity Assistant E did not follow proper hand hygiene while serving food to residents. Residents R2 and R4 were directly affected by the deficiencies in hand hygiene and food handling. Lead Activity Assistant E served their lunch with soiled gloves, touching various surfaces without washing hands or changing gloves. Interviews with staff, including KM P, RN G, and DON B, confirmed that proper procedures were not followed, and there was a lack of adherence to the facility's policies on hand hygiene and food handling. The deficiencies observed have the potential to impact the health and safety of all residents in the facility.
Inaccurate PBJ Reporting and Staffing Deficiencies
Penalty
Summary
The facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS). This deficiency has the potential to affect all 12 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting, triggering deficiencies for two fiscal year quarters for failure to have licensed nursing coverage 24 hours a day and one fiscal year quarter for failure to have Registered Nurse (RN) hours each day. The CMS's PBJ Staffing Data Report for fiscal year quarter 3 of 2023 indicated that the facility failed to have licensed nursing coverage 24 hours a day on multiple dates, with specific instances of less than 24 hours of coverage reported. Similarly, for fiscal year quarter 4 of 2023, the facility again failed to maintain 24-hour licensed nursing coverage on several dates and also failed to have RN hours on multiple days within the quarter. The CASPER Report 1702D and 1705D corroborated these findings, showing specific dates with insufficient licensed nursing and RN hours. During an interview, the Nursing Home Administrator (NHA) stated that the PBJ reporting was done correctly and that there was licensed coverage 24 hours a day. However, the NHA and Corporate Consultant were unable to reach the facility's accountant, who is responsible for the final report submission to CMS, during the survey period. The NHA provided documentation, including time punches and schedules, to prove that there was 24-hour licensed nurse coverage and RN coverage on the infraction dates, but the CASPER Report did not reflect this information.
Infection Control Deficiencies
Penalty
Summary
The facility did not establish and maintain an effective infection prevention and control program, which has the potential to affect all 12 residents. Staff were allowed to return to work too soon after reporting gastrointestinal symptoms and were not placed on the line list for respiratory symptoms. The facility failed to accurately document employees' symptom onset and did not evaluate whether staff should be working based on their symptoms. Additionally, the facility did not require staff to be tested for other communicable illnesses such as RSV or Influenza during cold and flu season. During an observation, a CNA performed catheter care on a resident with chronic kidney disease and urinary retention without appropriate hand hygiene. The CNA repeatedly changed gloves without performing hand hygiene, handled clean and dirty items interchangeably, and applied barrier cream without changing gloves. This improper technique was confirmed during an interview with the CNA, who admitted to not performing hand hygiene as required. The facility's policies were not followed, as evidenced by the lack of proper documentation and tracking of staff symptoms and the failure to ensure staff stayed home for the appropriate amount of time after symptoms resolved. The Director of Nursing confirmed that hand hygiene should be performed between cleansing, rinsing, and drying, which was not done in this case.
Failure to Provide Necessary ADL Services
Penalty
Summary
The facility failed to ensure that five residents received the necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Residents R1, R115, R4, R9, and R65 did not receive showers as scheduled, which was confirmed through observation, interviews, and record reviews. R1, who is cognitively intact, reported feeling grungy due to not receiving showers as scheduled. Documentation showed that R1 did not receive the required two showers per week as indicated in the care plan. Similarly, R115 and R4 also did not receive the scheduled showers, and R9 reported feeling like she smelled due to the lack of showers. The documentation for R9 showed multiple instances of missed showers or lack of proper documentation for refusals or unavailability. R65, who has multiple diagnoses including Parkinson's disease and dysphagia, was observed being left without food while his tablemates ate. When he was finally given food, he was not provided with utensils and had to use his fingers to eat. His plate was then moved out of his reach, and he was left to sit and watch others eat for 29 minutes before being assisted. This was contrary to his care plan, which stated that he should be allowed to participate in feeding as much as possible. The facility's policy on Activities of Daily Living, dated 6/29/21, states that residents who are unable to carry out activities of daily living should receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, the facility failed to adhere to this policy, resulting in residents not receiving the care they needed. Interviews with staff, including the Director of Nursing, confirmed that the expectation was for residents to receive showers twice a week and for all care and refusals to be documented, which was not consistently done.
Deficiency in Providing Resident-Centered Activity Programs
Penalty
Summary
The facility did not provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency affected seven residents who were reviewed for activities. The facility failed to incorporate social history assessment information into the care plans of these residents, resulting in care plans that were not person-centered. Residents voiced concerns about the lack of activity programming, and the facility did not create personalized care plans that included information collected during initial assessments, such as social history, familiar routines, past and present interests, and other personalized important information. For example, one resident, who was cognitively intact, had an activities assessment that included detailed personal information but did not have an activities care plan in their comprehensive care plan. Another resident with moderate cognitive impairment had a care plan that was not individualized or resident-centered, and the resident reported that there were no activities available. The facility's activity attendance records showed that the activities primarily consisted of reading a newsletter and occasional group activities, which were not aligned with the residents' interests and preferences. The facility's staff, including the Lead Activity Assistant and the Social Worker, acknowledged that the care plans should reflect the information gathered during initial assessments and be individualized to each resident's preferences, wants, and needs. However, the care plans reviewed did not include personalized interventions or measurable goals related to activities. The facility also failed to review activity attendance data to determine the effectiveness of the activity program for each resident. The Lead Activity Assistant lacked the qualifications and training to run the activity program effectively, and the Social Worker was overseeing the program without adequate involvement in the activity department.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting three residents in the dining area. One resident, who has multiple diagnoses including Parkinson's disease and cognitive communication deficit, was observed with uncombed hair, an unshaven face, and an uncovered catheter bag. This resident was seated at a table with other residents who were eating, but he was not given silverware and had to wait 29 minutes before receiving assistance with his meal. During this time, staff talked about the resident's altered diet and exposed catheter in front of him and other residents, further compromising his dignity. Another resident, who depends on staff for some needs and has a catheter, was observed in the dining area with her catheter bag uncovered, exposing the urine inside. This resident expressed a preference for the catheter bag to be covered when out of her room. Despite this, the catheter bag remained uncovered during the observation period. A third resident, who has diagnoses including bladder cancer and moderate cognitive impairment, was also observed with an uncovered catheter bag in the dining area. Staff acknowledged that catheter bags should be covered for both infection control and dignity reasons, but the resident's catheter bag was not covered until after the surveyor's observation. These incidents demonstrate a failure to uphold the residents' rights to dignity and respect as outlined in the facility's policies and federal regulations.
Failure to Include Resident's Suggested Pain Management Intervention in Care Plan
Penalty
Summary
The facility failed to ensure that a resident or their representative had the right to participate in the care planning process. Specifically, a resident (R2) attended a care plan conference and suggested an intervention to aid in her pain management during transfer, bed mobility, and toileting. However, this intervention was not considered when revising R2's care plan. As a result, R2 indicated she no longer gets out of bed due to staff not following the suggested intervention. The social worker (SW T) did not add the suggested intervention to R2's care plan and did not inform the front-line staff about it. R2 was admitted to the facility with multiple diagnoses, including a wedge compression fracture of the second lumbar vertebra, low back pain, and chronic kidney disease stage 3. Despite R2's comprehensive care plan addressing her pain management, the specific intervention she suggested during the care plan conference was overlooked. Interviews with R2 and staff confirmed that the intervention was not added to the care plan, and staff were not educated on implementing it. The Director of Nursing (DON B) acknowledged that the intervention should have been added and staff should have been educated on slower transfers and other activities of daily living (ADLs).
Failure to Implement Proper Hand Hygiene and Care Plan for Pressure Injury
Penalty
Summary
The facility failed to implement professional standards of practice to promote healing or prevent pressure injury (PI) development for a resident with a stage 3 PI of the sacral region. During wound care, improper hand hygiene techniques were observed, including the failure to perform hand hygiene after closing the resident's door, assisting the resident into bed, and touching the bed remote. Additionally, the nurse used contaminated 4 x 4 gauze pads and did not perform hand hygiene between glove changes, which is against the facility's hand hygiene policy dated August 2019. The resident's baseline care plan did not include specific interventions or goals related to the stage 3 PI, which is a violation of the facility's policy on baseline care plans dated December 2016. The care plan only mentioned maintaining universal precautions and following facility protocols for treatment but lacked detailed interventions to promote healing or prevent the worsening of the PI. This omission put the resident at risk of worsening the existing PI and developing new PIs. Interviews with the RN and DON confirmed the observed deficiencies. The RN acknowledged the failure to perform hand hygiene at critical points during wound care and admitted to using contaminated supplies. The DON also confirmed that hand hygiene should have been performed at the specified times and that contaminated supplies should not have been used. Both the RN and DON agreed that the baseline care plan should have included specific interventions to address the resident's stage 3 PI.
Inadequate Catheter Care and Infection Control
Penalty
Summary
The facility did not ensure that residents with catheters received appropriate treatment and services to prevent urinary tract infections. For Resident 113, who has diagnoses including bladder cancer and benign prostatic hyperplasia, the catheter drainage port was observed dragging on the floor during a transfer in a wheelchair. The CNA responsible for Resident 113 acknowledged that the catheter should not be dragging on the floor and adjusted it after being prompted by the surveyor. The Director of Nursing confirmed that catheters should not touch the floor due to infection control concerns. For Resident 9, who has diagnoses including malignant neoplasm of the kidney and cognitive communication deficit, the catheter was observed without a cover, exposing the urine inside. During the process of attaching a dignity bag to the wheelchair, the catheter made contact with the floor three times. The Director of Nursing confirmed that catheter bags should not be in direct contact with the floor. These observations indicate a failure to maintain proper catheter care and infection control practices for residents with catheters.
Failure to Monitor Dialysis Access Sites and Provide Emergency Interventions
Penalty
Summary
The facility did not ensure that a resident requiring dialysis received services consistent with professional standards of practice. The resident, who had diagnoses including end-stage renal impairment and hypertensive chronic kidney disease, had a chest port and an arteriovenous fistula in her arm. The facility's policy required monitoring of the dialysis access sites, but the resident's Medication Administration Record/Treatment Administration Record (MAR/TAR) did not include entries for monitoring the fistula every shift, including palpating the site to feel the thrill and using a stethoscope to hear the bruit of blood flow through the access. Additionally, the resident's Comprehensive Care Plan did not include interventions for emergency care if the resident was found to be bleeding from her fistula. Interviews with the resident and staff revealed that the staff did not regularly monitor the resident's fistula. The resident indicated that staff did not look at her arm, and a Certified Nursing Assistant (CNA) was unsure of the actions to take if the resident was found bleeding from her fistula. A Registered Nurse (RN) confirmed that the MAR/TAR only included monitoring of the chest port and that the fistula should also be monitored every shift. The Director of Nursing (DON) acknowledged that the care plan should include emergency interventions for the fistula and that staff should apply pressure and not leave the resident alone if bleeding occurred. The deficiency was further evidenced by the lack of documentation and training regarding the monitoring and emergency care of the resident's fistula. The DON and RN indicated that the necessary interventions and monitoring should have been in place and documented, but they were not. This oversight left the resident at risk for complications related to her dialysis access sites, as staff were not adequately prepared to handle potential emergencies involving the fistula.
Failure to Adhere to Weight Management Policy for New Admission
Penalty
Summary
The facility failed to adhere to its Weight Management policy for a new admission, resulting in a deficiency. A resident, identified as R4, was admitted with multiple health conditions, including rib fractures, muscle weakness, and cerebrovascular disease. The facility's policy required that new admissions be weighed the morning after admission and daily for two days, followed by weekly weigh-ins for four weeks. However, R4's weight was not recorded according to these standards. The only documented weights were from the resident's History and Physical, dated 4/21/24, showing 240 pounds, and a subsequent weight on 5/15/24, showing 233.6 pounds. R4 expressed concern about losing seven pounds since admission, which was confirmed by the surveyor's review of the medical records. The Director of Nursing (DON) acknowledged that the weight orders were not followed and admitted that an admission weight was necessary to assess the resident's condition accurately. The failure to obtain and document weights as per the facility's policy and physician orders led to the deficiency identified by the surveyor.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility did not ensure adequate supervision and safety to prevent accidents for a resident with a history of multiple falls. The resident, who was severely cognitively impaired and had a BIMS score of 00, experienced eight falls within a ten-day period. Despite the resident's high fall risk and multiple falls, the facility failed to implement effective fall interventions and provide adequate supervision. The resident's care plan included interventions such as keeping the bed at knee height and using a low bed, which contradicted each other. Additionally, the facility did not include a toileting schedule in the care plan, despite evidence suggesting that the resident was attempting to use the bathroom during several falls. The facility's fall reports consistently indicated
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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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