Oak Park Place Of Nakoma
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 4327 Nakoma Rd., Madison, Wisconsin 53711
- CMS Provider Number
- 525729
- Inspections on file
- 22
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Oak Park Place Of Nakoma during CMS and state inspections, most recent first.
The facility failed to follow its own discharge planning policy for three discharged residents by not completing required discharge summaries and, in one case, omitting a discharge goal from the care plan. The policy requires a discharge summary with a recap of the stay, a final status at discharge, and an individualized post‑discharge plan developed by the IDT with the resident and family, and that these documents be provided to the resident and filed in the medical record. For each of the three residents, the EMR showed a “Discharge Summary and Recap of Stay” assessment that was due and flagged in red as incomplete, and the DON confirmed these were not done as expected. One resident with progressive supranuclear palsy and palliative care needs had only a medication note on the discharge date with no summary; another with UTI, muscle weakness, cognitive communication deficit, and vascular dementia had a discharge summary entry that could not be opened and was acknowledged as not completed; and a third with a femur fracture and weakness was discharged home with home health services ordered but had no discharge summary documented and no discharge goal in the care plan.
A resident was allowed to self-administer a prescribed nasal spray without a documented assessment or care plan by the IDT or physician, as required by facility policy. Nursing staff left the medication at the bedside and acknowledged the resident's independent use, but there was no supporting documentation in the EMR.
A nurse, following instructions from an administrator, withdrew oxycodone tablets prescribed for one resident and administered them to another resident with a different physician order, resulting in a medication error. The incident involved residents with complex medical histories and occurred despite facility policy prohibiting the administration of medications ordered for one resident to another.
A resident with CHF did not receive daily weight monitoring as ordered by the physician, with significant gaps in documentation and inconsistent recording of refusals or physician notifications. Facility staff were unclear about responsibility for obtaining weights, and the resident experienced a substantial weight loss over three months without proper adherence to policy or orders.
A resident with multiple health conditions experienced severe, unplanned weight loss over several months. Despite physician orders for daily weights and notification requirements for significant changes, staff did not consistently obtain or document daily weights, nor did they notify the physician or NP of the weight loss or refusals. The DON confirmed these actions were not documented or communicated as required.
The facility failed to document vital signs and follow physician orders for several residents, leading to non-compliance with professional standards. Residents with conditions such as hypertension, diabetes, and cognitive impairments had missing records for vital signs and blood glucose checks, despite active orders. Interviews with staff revealed confusion about documentation processes.
A facility failed to thoroughly investigate an alleged neglect incident involving a resident with multiple health issues. The resident's POA expressed concerns about inadequate attention during the resident's stay. Although the NHA initiated an investigation and communicated with the POA, they did not interview other residents, which was required by the facility's policy.
A resident with a complex medical history experienced significant medication errors due to the omission of multiple prescribed medications over a period. The facility's MAR showed numerous instances of unadministered medications without proper documentation or physician notification. Interviews with staff revealed a lack of understanding and adherence to medication administration policies, highlighting systemic issues in medication management and documentation.
The facility failed to ensure safe food handling practices, affecting all 14 residents. A cook's hair was not fully covered, and raw meat was improperly stored, risking cross-contamination. The Dietary Manager confirmed these issues and took steps to correct them.
The facility did not ensure medications were accurately labeled and disposed of when beyond expiration for several residents. An LPN administered insulin pens without open dates, and a medication cart contained undated medications, contrary to policy and manufacturer guidelines. The DON confirmed the medications should have been dated upon opening.
A resident with multiple diagnoses was transferred to the hospital without receiving a required written transfer notice. The notice should have included the date, reason, location of the transfer, appeal rights, and contact information for the State LTC Ombudsman. The absence of this notice was confirmed by a Corporate RN during an interview.
A facility did not provide a bed hold notice to a resident or their emergency contact when the resident was transferred to the hospital. The facility's policy requires written notice of bed hold policies to be given at least twice, but this was not done for a resident with multiple diagnoses, including acute kidney injury and pulmonary embolism. A Corporate RN confirmed the oversight during an interview.
A resident's CPAP machine was not cleaned according to the facility's policy, which required daily cleaning. The resident, with severely impaired cognition, could not recall seeing the CPAP mask cleaned. Staff interviews revealed confusion about cleaning responsibilities, with CNAs and LPNs unsure of their roles. The DON expected adherence to the policy but could not confirm the cleaning process.
A resident prescribed lamotrigine and oxycodone was not monitored for adverse reactions or side effects, contrary to the facility's Medication Therapy policy. The resident's medical record lacked documentation of such monitoring, and the Corporate RN confirmed the absence of side effect monitoring in the Medication Administration Record or care plan.
The facility failed to maintain proper infection control practices. An LPN did not sanitize a blood pressure cuff before or after use on a resident, and another LPN entered a resident's room on contact isolation precautions without wearing PPE. Both staff members acknowledged their oversights, and the DON confirmed the expectations for sanitization and PPE use.
The facility failed to ensure pneumococcal vaccinations were reviewed, offered, or administered for two residents. One resident's vaccination history was not reviewed, and they were not offered the PCV20 vaccine. Another resident, who had previously received PPSV23 and PCV13 vaccines, was not offered the PCV20 vaccine as per CDC guidelines. The Corporate RN acknowledged the facility's non-compliance with vaccination updates.
The facility failed to document and ensure the administration of updated COVID-19 vaccines to two residents. Despite previous vaccinations, there was no record of offering, declining, or administering the updated vaccines as per CDC and ACIP guidelines. A CRN acknowledged the facility's lapse in maintaining up-to-date COVID-19 vaccinations.
Failure to Complete Required Discharge Summaries and Goals for Three Discharged Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Discharge Summary and Plan policy for three residents reviewed for discharge planning. The policy, dated 10/2022, requires that when a discharge is anticipated, staff complete a discharge summary including a recapitulation of the resident’s stay, a final summary of status at discharge, and an individualized post‑discharge plan developed by the interdisciplinary team with the resident and family. The policy also requires that an evaluation of discharge needs, the post‑discharge plan, and the discharge summary be provided to the resident and filed in the medical record. For all three residents (R1, R2, and R3), the electronic medical record in Point Click Care showed a “Discharge Summary and Recap of Stay” assessment that was due and highlighted in red as overdue or not completed, and the DON confirmed these discharge summaries were not completed as expected on the day of discharge. R1, admitted for a respite stay with diagnoses including progressive supranuclear palsy and palliative care needs, had a care plan focus on preparing for discharge, but on the discharge date the only progress note entry was a medication entry with the word “discharged” and no discharge summary was present. R2, admitted with diagnoses including UTI, muscle weakness, cognitive communication deficit, and vascular dementia, was discharged to a private residence, but the “Discharge Summary and Recap of Stay” assessment in the record was highlighted in red and could not be opened, and the DON stated this meant it was not completed. R3, admitted with a left femur neck fracture and weakness and discharged home with home health PT and OT ordered, had progress notes on the day of discharge documenting pain monitoring and analgesic orders but no discharge summary or mention of discharge, and the care plan dated 12/10/25 did not include a discharge goal. The DON acknowledged that discharge summaries should be completed on the day of discharge and that residents’ care plans should include a discharge goal, which was not done for these residents.
Failure to Assess and Document Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications as required by facility policy. The policy states that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determines the resident has the decision-making capacity to do so safely. Review of the resident's electronic medical record, care plan, assessments, progress notes, and physician orders revealed there was no documented assessment or care plan addressing the resident's ability to self-administer medications. No orders related to self-administration were found, and there was no evidence of an interdisciplinary team meeting or progress note documenting this capability. Despite the lack of assessment and documentation, the resident was observed self-administering a prescribed nasal spray medication in her room, with the medication being left at her bedside for her use. The resident confirmed during interview that she had been self-administering the nasal spray independently for a long time, and nursing staff acknowledged that the medication was routinely left in the resident's room for her to use on her own. The DON stated that such practices should be documented in the assessments, care plan, and IDT meeting notes, but this was not done for this resident.
Medication Borrowing Results in Failure to Meet Professional Standards
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards and facility policy, resulting in a medication ordered for one resident being administered to another. Specifically, a registered nurse withdrew two oxycodone 5 mg tablets from one resident's medication supply and administered them to a different resident, despite each resident having distinct physician orders for their pain medication. This action was taken after the nurse consulted with the facility administrator, who approved the borrowing of medication, even though the facility's policy explicitly prohibits administering medications ordered for one resident to another unless permitted by state law and approved by the director of nursing services. The incident involved two residents with significant medical histories. One resident had diagnoses including pain in the left knee and hip, diabetes, and cognitive communication deficit, and had an order for oxycodone 5 mg to be given as needed. The other resident, who received the borrowed medication, had diagnoses such as spinal stenosis, muscle weakness, chronic embolism, and severe pain at the time of administration, with a physician's order for oxycodone 10 mg as needed. The medication administration records and controlled drug use records confirmed that the medication was not administered as prescribed and that the nurse documented the borrowing of medication in the records. Interviews with the nurse and facility leadership revealed that the nurse acted under the direction of the administrator, who was attempting to address a situation involving a resident in severe pain and a dissatisfied family. The nurse acknowledged that she did not initially consider the action a medication error, as she believed she was resolving an urgent issue, but later recognized it as such. The director of nursing was not present at the facility during the incident and was informed after the fact.
Failure to Monitor Daily Weights for CHF Resident
Penalty
Summary
Nursing personnel failed to follow physician orders and facility policy regarding daily weight monitoring for a resident diagnosed with congestive heart failure (CHF). The resident had clear orders from both the nurse practitioner and physician for daily weights to monitor CHF, with instructions to notify the provider if there was a significant weight change. However, the medical record and weight logs showed that weights were not obtained daily as ordered, with large gaps between recorded weights. The Medication Administration Record (MAR) indicated weights were sometimes completed, refused, held, or marked as 'other/see progress notes,' but the actual weight record only showed sporadic entries. Over a three-month period, the resident experienced a significant weight loss of 43.4 lbs, yet daily monitoring was not consistently performed or documented. Interviews with facility staff, including the Director of Nursing (DON) and Physical Therapy Director (PTD), revealed confusion and lack of clarity regarding responsibility for obtaining weights. The DON acknowledged awareness of the daily weight order and agreed that refusals and physician notifications should be documented, but could not provide evidence that refusals or physician notifications were consistently recorded. The PTD denied that therapy staff were responsible for weighing residents, despite a progress note suggesting otherwise. The facility's own policies required prompt notification of significant changes in condition and documentation of refusals, but these were not followed in this case.
Failure to Monitor and Report Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and did not consult with the resident's physician regarding significant weight loss for one resident. The resident, who had diagnoses including a lumbar fracture, CHF, cognitive communication deficit, and type 2 diabetes, experienced a severe weight loss of 15.3% over two months. Physician orders required daily weights due to CHF, with instructions to notify the nurse practitioner if there was a weight gain or loss of 3 lbs. in a day or 5 lbs. in a week. However, the medical record and MAR showed that weights were not consistently obtained daily as ordered, with some days marked as refused, held, or referencing progress notes. The resident's weight dropped from 280 lbs. to 238 lbs. over three months, a loss of 43.4 lbs., which is classified as severe. The Director of Nursing (DON) confirmed awareness of the daily weight order and acknowledged that the physician should have been notified of the severe weight loss and refusals. There was no documentation that the physician or nurse practitioner was updated about the weight loss or refusals, nor was there evidence that the risks and benefits of refusing weights were explained to the resident. The facility's policy required immediate notification of the dietician and physician for significant weight changes, but these steps were not documented or followed in this case.
Failure to Document Vital Signs and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that the services provided by nursing personnel met professional standards of quality for five residents. Specifically, the facility did not complete physician orders for daily vital signs for residents R5, R8, R9, R10, and R1. The facility's policy requires that vital signs be documented daily, and any abnormalities be reported to a physician. However, the records show multiple instances where vital signs were not recorded as ordered. Resident R5, who was admitted with conditions including a periprosthetic fracture and hypertension, had several days where vital signs were not documented. Similarly, resident R8, admitted with osteomyelitis and hypertension, also had missing vital sign records on multiple days. Resident R9, with severe cognitive impairment and a history of stroke, and resident R10, with metabolic encephalopathy and atrial fibrillation, both had numerous days where vital signs were not recorded, despite active orders for daily monitoring. Resident R1, admitted with cellulitis and diabetes, had orders for frequent blood glucose checks and daily vital signs. However, there were gaps in the documentation of these checks, and the Medicare charting was not completed daily as required. Interviews with the Director of Nursing and an LPN revealed a lack of clarity regarding the documentation process, with blank boxes on the Medication Administration Record indicating potential non-compliance with physician orders.
Incomplete Investigation of Alleged Neglect
Penalty
Summary
The facility failed to ensure a thorough investigation of alleged neglect for a resident, identified as R3, during their stay from November 1 to November 4, 2024. R3's Power of Attorney (POA) expressed concerns about possible neglect, stating that R3, who was unable to move their arms or legs, did not receive adequate attention. The Nursing Home Administrator (NHA) initiated an investigation and maintained communication with the POA, but did not interview other residents to determine if there were additional concerns or allegations. The facility's policy requires all possible incidents of abuse, neglect, or mistreatment to be identified and investigated, which was not fully adhered to in this case. R3 was admitted with multiple diagnoses, including respiratory failure, heart disease, and major depressive disorder. The POA reported to the hospital that R3 felt neglected, which prompted the hospital to inform the facility. Although the NHA collected statements from staff and communicated with the POA, the investigation was deemed incomplete as it did not include interviews with other residents. The POA later clarified that the term 'neglect' was used to express concern over the level of attention R3 received, rather than an accusation of neglect. Despite this clarification, the facility did not conduct a comprehensive investigation as required by their policy.
Resident Medication Errors Due to Omission and Documentation Failures
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the omission of multiple medications over a period in December and January. The resident, who was admitted on December 20, 2024, had a complex medical history including conditions such as cellulitis, hyperlipidemia, paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, epilepsy, chronic pain, hypertension, portal vein thrombosis, benign prostatic hyperplasia, and a history of transient ischemic attack and cerebral infarction. The resident's discharge medication list included critical medications for managing these conditions, such as insulin glargine, semaglutide, zonisamide, apixaban, levetiracetam, mycophenolate, tacrolimus, and ursodiol, among others. The Medication Administration Record (MAR) for the resident documented numerous instances where medications were not administered as prescribed. The chart codes indicated that some medications were marked with a '9', meaning 'other/see progress notes', but there were no corresponding progress notes to explain the omissions. Additionally, some medications had blank entries on the MAR, which staff were unable to explain. Interviews with the LPN and DON revealed a lack of clarity and understanding regarding the documentation codes and procedures for handling medication omissions, indicating a breakdown in communication and adherence to the facility's medication administration policies. The surveyor's interviews with the LPN and DON highlighted a lack of awareness and understanding of the facility's procedures for documenting and addressing medication errors. The DON acknowledged that medications should be administered as ordered and that any unavailability should be addressed by checking the automatic dispensing unit or contacting the pharmacy. However, the failure to document reasons for medication omissions and the lack of physician notification suggest systemic issues in medication management and documentation practices within the facility.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure safe food handling practices, which had the potential to affect all 14 residents. During a kitchen tour, a cook was observed with a hat and hair net that did not fully cover their long hair, contrary to the Wisconsin Food Code and the facility's Hair Restraints policy. The Dietary Manager confirmed that the cook's hair should have been fully covered and provided a larger hair net. Additionally, raw meat was improperly stored in the walk-in cooler, posing a risk of cross-contamination. Raw ground hamburger and boneless chicken breasts were stored on the same shelf without equipment to prevent dripping, and sweet potatoes were stored alongside raw chicken. The facility's Food Storage policy and a sign in the cooler outlined proper storage arrangements, which were not followed. The Dietary Manager acknowledged the improper storage and rearranged the items to comply with the guidelines.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure medications were accurately labeled and disposed of when beyond the expiration date for several residents. During a medication administration observation, an LPN administered insulin pens to two residents without open dates, which is against the facility's policy that requires multi-dose vials to be dated upon opening. The LPN confirmed that the insulin pens should have been dated and are only good for 28 days after opening. Additionally, a surveyor observed a medication cart containing open and undated medications for four residents. These included an insulin glargine pen, latanoprost eye drops, a Stiolto inhaler, and a bottle of calcitonin nasal spray, all of which lacked open dates. Manufacturer recommendations for these medications specify storage conditions and timeframes for use after opening, which were not adhered to. The Director of Nursing confirmed that staff should have dated the medications when they were opened.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide a required transfer notice to a resident, identified as R14, who was transferred to the hospital. R14 was admitted to the facility with diagnoses including acute kidney injury, adjustment disorder with depressed mood, unspecified fall, and pulmonary embolism. On the date of transfer, R14's Minimum Data Set (MDS) assessment did not indicate an assessment for cognition, and there was no activated Power of Attorney (POA) for R14. Despite these circumstances, neither R14 nor R14's emergency contact received a written transfer notice that included essential information such as the date, reason, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This deficiency was confirmed during an interview with the Corporate Registered Nurse (CRN)-C, who acknowledged the absence of a transfer notice for R14's hospital transfer.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, identified as R14, or their emergency contact when the resident was transferred to the hospital. According to the facility's Bed-Holds and Returns policy, residents and/or their representatives should be informed in writing about the bed hold policies at least twice: well in advance of any transfer and at the time of transfer, or within 24 hours if the transfer was an emergency. R14 was transferred to the hospital on 8/10/24, but the medical record did not indicate that a bed hold notice was provided. During an interview on 9/18/24, a Corporate Registered Nurse confirmed that the facility did not issue a bed hold notice for R14's hospital transfer. R14's medical record included diagnoses such as acute kidney injury, adjustment disorder with depressed mood, unspecified fall, and pulmonary embolism, but did not show an assessment for cognition or an activated Power of Attorney.
Failure to Clean CPAP Machine as per Policy
Penalty
Summary
The facility failed to ensure that a CPAP machine was cleaned according to its policy for a resident with obstructive sleep apnea. The facility's policy required daily cleaning of CPAP masks, nasal pillows, and tubing by soaking them in warm, soapy water for five minutes, rinsing with warm water, and allowing them to air dry. However, observations and interviews revealed that the CPAP machine used by the resident was not cleaned as per the policy. The resident, who had severely impaired cognition and an activated Power of Attorney for Healthcare, was unable to recall seeing staff clean the CPAP mask since admission. Interviews with staff members, including CNAs and LPNs, indicated a lack of clarity and responsibility regarding the cleaning of CPAP equipment. One CNA mentioned that the AM shift CNAs were responsible for cleaning the CPAP mask and equipment, while another CNA stated that they did not clean the mask, assuming a nurse would do so. An LPN also indicated that they did not handle CPAP machines or equipment. The Director of Nursing was unable to provide information on the cleaning process but expected staff to follow the facility's policy.
Failure to Monitor High-Risk Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for adverse reactions or side effects of high-risk medications. The resident, identified as R2, was prescribed lamotrigine, an anticonvulsant, and oxycodone, an opioid, without a plan of care that included monitoring for potential side effects. The facility's Medication Therapy policy requires that each resident's medication regimen be reviewed to identify potential or suspected side effects, but this was not done for R2. R2 was admitted with diagnoses including spondylosis and bipolar disorder and had a BIMS score indicating intact cognition. Despite these conditions, the medical record lacked documentation of monitoring for adverse reactions to lamotrigine and oxycodone. During an interview, the Corporate Registered Nurse confirmed that there was no side effect monitoring in place for R2's medications, which should have been documented in the Medication Administration Record or care plan.
Infection Control Deficiencies in Equipment Sanitization and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff members. In the first incident, a Licensed Practical Nurse (LPN) did not sanitize a blood pressure cuff before or after using it on a resident, despite the facility's policy requiring the sanitization of multi-use equipment between residents. This was confirmed by the LPN during an interview with the surveyor, who acknowledged the oversight. In the second incident, another LPN entered the room of a resident on contact isolation precautions for Clostridium difficile without donning the required personal protective equipment (PPE), such as a gown and gloves. The LPN admitted to missing the contact isolation precautions sign posted outside the resident's room and confirmed that PPE should have been worn. The Director of Nursing verified that staff are expected to follow PPE protocols as indicated by signage for residents on contact isolation precautions.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were reviewed, offered, or administered for two residents, R12 and R10, out of a sample of five. For R12, the facility did not review the resident's vaccination history or offer the PCV20 vaccine. R12's medical record lacked documentation of receiving either the PPSV23 or PCV13 vaccines, and there was no indication that the PCV20 vaccine was offered or administered. For R10, the resident had previously received a PPSV23 vaccine in 2009 and a PCV13 vaccine in 2015. However, the facility did not offer or administer the PCV20 vaccine, as recommended by the CDC guidelines. The Corporate Registered Nurse acknowledged that the facility was not up to date with pneumococcal vaccinations and was in the process of implementing their policies.
Failure to Document and Administer Updated COVID-19 Vaccines
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered, declined, or administered to two residents, R12 and R10, as per the guidelines. R12 was admitted to the facility and had previously received a COVID-19 vaccine on August 5, 2021. However, there was no documentation in R12's medical record indicating that an updated COVID-19 vaccine was offered, declined, or administered. Similarly, R10, who was admitted to the facility and had received a COVID-19 vaccine on June 28, 2022, also lacked documentation in their medical record regarding the offer, declination, or administration of an updated COVID-19 vaccine. The surveyor's review of the medical records on September 18, 2024, revealed these deficiencies. During an interview on the same day, the Corporate Registered Nurse (CRN)-C acknowledged that the facility was not up to date with COVID-19 vaccinations and was in the process of implementing their policies. This lack of documentation and failure to offer or administer updated COVID-19 vaccines to the residents constitutes a deficiency in the facility's adherence to CDC guidelines and the Advisory Committee on Immunization Practices (ACIP) recommendations.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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