Oakwood Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Altoona, Wisconsin.
- Location
- 2512 New Pine Dr, Altoona, Wisconsin 54720
- CMS Provider Number
- 525454
- Inspections on file
- 26
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Oakwood Health Services during CMS and state inspections, most recent first.
A resident with cognitive impairment and right-sided paralysis was transferred using a large Hoyer lift sling instead of the care planned medium size, despite clear documentation and recent staff education. The error was discovered during a surveyor observation, and the CNA confirmed the care plan requirements had not been followed.
A resident with Parkinson's disease was subjected to a straight catheterization against her will, resulting in immediate jeopardy. Despite her objections, an RN and two CNAs proceeded with the procedure, holding her down while she cried and resisted. The resident did not meet the facility's criteria for a urine culture, as she did not have a fever. The incident was reported to law enforcement and APS, and the resident was transferred to a hospital after expressing feelings of unsafety.
The facility failed to establish an effective Infection Control Program, leading to deficiencies in infection prevention and control practices. Incomplete infection control logs, improper use of PPE, and inadequate hand hygiene were observed. A resident was placed on prolonged contact precautions without justification, and Enhanced Barrier Precautions were not implemented for a resident with an indwelling catheter. These actions indicate a lack of adherence to infection control protocols, potentially affecting all residents and staff.
A resident with intact cognition and a desire to smoke was not provided a person-centered care plan addressing his smoking preferences. Despite the facility's policy allowing smoking in designated areas, the resident's care plan lacked specific interventions, leading to frustration and negative behaviors. Staff were unable to consistently accommodate the resident's smoking requests due to time constraints, impacting the resident's quality of life.
A resident with limited ROM did not receive documented ROM exercises as per their care plan. Despite staff claims of performing exercises, no documentation was found. The DON acknowledged the lack of documentation, and the NHA noted gaps in the restorative program.
A resident with mobility issues and a risk for falls was transferred without the use of a gait belt, contrary to facility policy. The CNA assisting the resident did not use a gait belt, instead holding the resident's pant waist band and underarms. Interviews with staff revealed that the use of a gait belt is expected during transfers, but the CNA was not instructed to do so, highlighting a communication gap in policy adherence.
The facility failed to provide appropriate pressure ulcer care for two residents, leading to the development of severe pressure injuries. One resident developed an unstageable pressure injury and sepsis due to lack of notification and intervention, while another resident's care plan was not followed, resulting in unaddressed pressure injury risks. The deficiency was marked by inadequate communication, documentation, and implementation of care plans.
A resident with multiple health issues developed a deep tissue injury and experienced changes in vital signs, including tachycardia and low blood pressure, without the facility notifying the physician. The resident's condition, which included a pressure injury and potential signs of sepsis, was not communicated to the physician until the resident was sent to the emergency room.
The facility failed to implement an effective Infection Control Program, resulting in a scabies outbreak affecting staff and residents. Infected staff continued working across multiple units, spreading the infection. The facility lacked timely documentation and contact precautions, and did not conduct comprehensive skin assessments. Leadership was unaware of the outbreak's extent, delaying surveillance and treatment efforts.
A resident with a history of constipation was admitted to a facility and did not receive appropriate bowel management care. Despite having orders for medications like MiraLAX and Senna Plus, and standing orders for Milk of Magnesia, Bisacodyl suppository, and Fleets enema, there was no documentation of these being administered. The facility lacked a bowel management policy and did not conduct a formal bowel assessment. The resident expressed feeling constipated and refused a bedpan, preferring other options that were not documented as given. The resident was transferred to the hospital after not having a bowel movement for four days.
A resident at high risk for dehydration did not have their fluid intake properly calculated or monitored by the facility. Despite being on a diuretic and having a history of conditions that increase dehydration risk, the resident's fluid intake was significantly below the recommended levels. Interviews with staff confirmed the lack of assessments to ensure adequate hydration.
Incorrect Hoyer Sling Size Used for Dependent Resident
Penalty
Summary
Staff failed to ensure the correct size Hoyer lift sling was used for a resident with right-sided paralysis, contracture, neglect syndrome, and dementia. The resident's care plan and medical record specified the use of a medium (purple) sling for all mechanical lift transfers, in accordance with the manufacturer's guidelines and the resident's weight. However, during observation, the resident was found seated in a broda chair with a green (large) sling in use, contrary to the care plan instructions. The Certified Nursing Assistant (CNA) involved confirmed the care plan required a medium sling and expressed surprise at the error, despite recent education and skill checks provided to staff. The facility's policy mandates that resident handling and transfers be performed according to each resident's individual plan of care to minimize injury risk. The deficiency was identified when the surveyor observed the incorrect sling in use and verified the care plan documentation with the CNA. The Nursing Home Administrator confirmed that all other residents requiring Hoyer lifts were checked and found to have the correct sling size, with the exception of this resident.
Resident Subjected to Unwanted Catheterization
Penalty
Summary
The facility failed to protect a resident from mental abuse by staff, which resulted in immediate jeopardy. The incident involved a resident with Parkinson's disease who was cognitively intact and her own decision-maker. The resident was subjected to a straight catheterization procedure against her will, despite her clear verbal objections and physical resistance. The procedure was carried out by an RN with the assistance of two CNAs, who held the resident down while she cried and pleaded for them to stop. The resident had been experiencing urinary discomfort, and a physician had ordered a urine sample. However, the facility's criteria for obtaining a urine culture required the presence of a fever, which the resident did not have. Despite this, the RN proceeded with the catheterization, claiming not to have heard the resident's objections. The CNAs involved expressed discomfort with the situation but followed the RN's instructions, later reporting the incident to the Director of Nursing. The incident was reported to law enforcement and Adult Protective Services, and the resident expressed feeling unsafe in the facility. The resident's family noted a decline in her condition following the incident, and she was eventually transferred to a hospital. The facility's failure to respect the resident's right to refuse treatment and protect her from abuse led to the finding of immediate jeopardy.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to establish an effective Infection Control Program, which led to several deficiencies in infection prevention and control practices. The facility did not have a proper surveillance system in place to track and monitor infections among residents and staff. The infection control logs were incomplete, lacking critical information such as symptom onset and resolution dates, diagnostic results, and analysis of infections. The Director of Nursing (DON) acknowledged the absence of a consistent documentation procedure for infection surveillance prior to November 2024 and admitted that no written improvement plan was in place. In one instance, a resident was placed on contact precautions after a single episode of vomiting, despite negative COVID-19 tests and no further symptoms. The facility's surveillance data was inaccurately completed, and the resident remained on precautions longer than the recommended 48-hour period for gastrointestinal symptoms. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter upon admission, as required by their policy. The facility also demonstrated improper use of Personal Protective Equipment (PPE). A Certified Nursing Assistant (CNA) with a full beard was observed wearing an N95 mask without a proper seal, and contaminated PPE was disposed of in non-COVID positive resident rooms. Furthermore, another CNA failed to practice proper hand hygiene during personal care for a resident, continuing to use the same gloves throughout various tasks without washing or sanitizing hands. These actions indicate a lack of adherence to infection control protocols, potentially affecting all residents and staff in the facility.
Failure to Develop Person-Centered Care Plan for Resident's Smoking Preferences
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident, identified as R35, which did not address the resident's preference for smoking. Despite R35's intact cognition and expressed desire to smoke, the comprehensive care plan lacked specific interventions to accommodate this preference. The facility's policy allows residents deemed safe to smoke in designated areas, yet R35's care plan did not reflect his smoking preferences, leading to frustration and negative behaviors. R35, who has diagnoses including dementia, anxiety, and depression, expressed a desire to smoke regularly, but reported being able to smoke only once a week. The resident's cigarettes were stored in a locked medication cart, and staff were reportedly unable to supervise R35's smoking due to time constraints. Interviews with staff revealed that while R35 frequently requested to smoke, the staff could not consistently accommodate these requests, leading to R35's frustration and feelings of being ignored. The surveyor observed that R35's care plan was updated to reflect risks associated with smoking-related injuries but did not include interventions to address his smoking preferences. Despite the facility's policy to accommodate smoking requests, staff interviews indicated that scheduled smoking times were not consistently applied, and R35's requests were only met when staff were available. This lack of a person-centered approach in the care plan potentially impacted R35's quality of life and care.
Failure to Document and Implement ROM Care Plan
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase or maintain ROM, as outlined in the resident's care plan. The resident, who was admitted with diagnoses including hemiplegia, rheumatoid arthritis, and a right shoulder contracture, had a care plan that included specific ROM exercises. However, there was no documentation in the resident's electronic medical record indicating that these exercises were completed, despite the care plan's requirements. Interviews with facility staff revealed that ROM exercises were reportedly performed by a Certified Nursing Assistant (CNA) during morning care, but no documentation was found to support this claim. The Director of Nursing (DON) acknowledged that the facility's restorative binder contained only care plans and lacked documentation of completed exercises. The Nursing Home Administrator (NHA) noted a change in leadership and identified gaps in the restorative programs, indicating that the facility was working on addressing these issues.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to use a gait belt during the transfer of a resident, identified as R9, which is a violation of their policy on safe resident handling and transfers. R9, who has diagnoses including anxiety disorders, osteoarthritis, a right artificial knee, abnormalities of gait and mobility, and generalized muscle weakness, requires assistance with activities of daily living (ADLs) and is at risk for falls. The care plan for R9 specifies the need for assistance from one staff member during transfers but does not explicitly mention the use of a gait belt. During an observation, a Certified Nursing Assistant (CNA) assisted R9 with transfers without using a gait belt, instead holding onto R9's pant waist band and underarms. Interviews with the CNA and other staff, including Occupational Therapy (OT) and Physical Therapy (PT) personnel, revealed that the expectation is to use a gait belt for any assistive transfers unless the resident declines its use. The Director of Nursing (DON) confirmed that the transfer assessment should be documented in the care plan and that the use of a gait belt is expected during transfers. The CNA admitted to not using a gait belt with R9 and stated that she was not instructed to do so, indicating a gap in communication and adherence to the facility's policy.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. Upon admission, one resident was identified with a suspected deep tissue injury (DTI) from the coccyx to the peri area, but the physician, Director of Nursing (DON), or wound nurse were not notified. No care plan or interventions were put in place, and pressure injury assessments were not completed. This oversight led to the development of an unstageable pressure injury and sepsis, requiring hospitalization and surgical intervention. Another resident was admitted with a pressure injury on the left heel, but the care plan interventions, such as floating the heels, were not consistently implemented. Observations by the survey team noted that the resident's heels were not floated during multiple instances, and there was a lack of documentation regarding the assessment and resolution of the pressure injury. The staff, including CNAs and RNs, were not aware of the necessary interventions or the current status of the resident's pressure injury. The facility's failure to implement pressure injury interventions and assess the residents' conditions created a finding of immediate jeopardy. The lack of communication and documentation regarding the residents' pressure injuries and the absence of individualized care plans contributed to the deficiency. The facility did not ensure that each resident received care consistent with professional standards of practice to prevent pressure injuries.
Removal Plan
- Facility in-house residents had their skin inspected by RN and no unidentified pressure injuries were discovered, current interventions were reviewed and verified in place as per care plan, and treatment orders are in place, accurate, and completed as ordered.
- Re-education to licensed nursing staff (RNs and LPNs) for aggressive pressure injury prevention including visually inspecting resident's skin upon admission or readmission to identify skin impairments, notifying physician to obtain orders for treatment, notifying responsible party of resident, and interdisciplinary team (IDT) re-educated on pressure injury and non-pressure injury, need to review new or worsening skin impairments to ensure interventions are reviewed and care plan updated.
- Re-education to nursing staff to monitor skin for injuries or changes with cares to ensure current he nurse if noted.
- DON or designee to review facility charting to ensure new admissions, readmissions, and current residents have skin impairments properly documented, orders implemented, and notifications completed and documented. This review will then be completed 5 days per week for 6 weeks or until substantial compliance maintained.
- Audits will be completed by DON or IDT to ensure in house residents with pressure injuries have established wound process in place including care plan review and evaluation.
- Quality Assurance Performance Improvement (QAPI) meeting held to review pressure injury incident, discuss implementation of actions items as stated above.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician about a change in condition, specifically for a resident who developed a deep tissue injury (DTI) and experienced changes in vital signs. The resident, who was admitted with diagnoses including malnutrition, multiple myeloma, and a left hip fracture, was assessed with a Braden Scale score indicating no risk for skin breakdown. However, a weekly skin assessment revealed a DTI on the coccyx, but there was no documentation of physician notification regarding this injury. Additionally, the resident experienced tachycardia and a drop in blood pressure, which are potential signs of sepsis, yet there was no documentation of physician notification for these changes either. The resident expressed concerns about her heart, and despite regular auscultation, the facility did not notify the physician until the resident was sent to the emergency room. The physician confirmed that they were not informed of the DTI or the changes in heart rate and blood pressure until the transfer to the hospital was requested.
Inadequate Infection Control Leads to Scabies Outbreak
Penalty
Summary
The facility failed to establish an effective Infection Control Program, which led to an outbreak of scabies affecting both staff and residents. The facility did not have a tracking program in place for the early detection of infected and exposed individuals, resulting in multiple nursing staff members working while infected and subsequently exposing residents across different units. The outbreak timeline revealed that several staff members, including CNAs and an RN, developed symptoms and were treated for scabies, but continued to work on various halls, spreading the infection further. The facility's response to the outbreak was inadequate, as evidenced by the lack of documentation and timely implementation of contact precautions. For instance, a resident on Cedar Hall developed a rash but was not placed on contact precautions until two weeks later. Additionally, there was no documentation of skin scrapings to confirm scabies, and the facility did not conduct skin assessments on all units, despite the presence of symptomatic staff and residents. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) only conducted a full body review on Aspen Hall, neglecting other potentially affected areas. Interviews with facility leadership revealed a lack of awareness and timely action regarding the outbreak. The DON admitted to not taking action when initially informed about staff members with scabies, and the facility only began surveillance efforts after the outbreak was deemed active. Furthermore, there was no resident line list or monitoring for rashes on certain halls, and the facility failed to treat all exposed residents promptly. The report highlights the facility's failure to implement necessary infection control measures, resulting in the spread of scabies among residents and staff.
Failure to Provide Adequate Bowel Management for Resident
Penalty
Summary
The facility failed to provide appropriate care and services to a resident (R2) to promote regular bowel movements in accordance with the resident's preferences, goals for care, and professional standards of practice. R2 was admitted to the facility with a history of constipation and was dependent on staff for toileting and transfers. Despite being on medications such as MiraLAX and Senna Plus for constipation, and having standing orders for Milk of Magnesia, Bisacodyl suppository, and Fleets enema, there was no documentation of R2 receiving these as-needed medications during their stay. R2 expressed feeling constipated and refused the option of using a bedpan, preferring other options like Milk of Magnesia and a suppository, which were not documented as administered. The facility lacked a policy or procedure on bowel management and did not conduct a formal bowel assessment for R2. The medical record review showed no documentation of a bowel movement during R2's stay, and the Director of Nursing and a Registered Nurse confirmed the absence of a bowel assessment and documentation of administered as-needed medications. The expectation was for nurses to provide Milk of Magnesia and prune juice, and if no bowel movement occurred by the next day, to administer a suppository. The facility's failure to adhere to these expectations and lack of documentation led to R2's transfer to the hospital after not having a bowel movement for four days.
Failure to Monitor Fluid Intake for High-Risk Resident
Penalty
Summary
The facility failed to calculate the fluid intake for one of three sampled residents, identified as R2, who was at high risk for dehydration. The facility's policy on hydration requires offering sufficient fluid to each resident to maintain proper hydration and health, with a minimum fluid intake of 1500 cc per day recommended by guidelines. However, R2's fluid intake records showed significantly lower amounts on several days, with no assessments completed to monitor for dehydration or to recommend appropriate fluid intakes. R2 was admitted with a diagnosis of compression fracture and a history of constipation, and was receiving Furosemide, a diuretic that increases fluid loss, further increasing the risk of dehydration. Interviews with the Director of Nursing and a Registered Nurse confirmed the absence of assessments to ensure R2 was receiving the recommended fluid intake. Additionally, the Dietary Manager acknowledged that an assessment of R2's nutritional and fluid needs was not completed, although it would have recommended a daily intake of 2100 to 2500 cc. The facility's failure to assess and monitor R2's fluid intake, despite the resident's high risk for dehydration, constitutes a deficiency in providing adequate hydration to maintain health.
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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