Oakwood Village East Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Wisconsin.
- Location
- 5833 American Parkway, Madison, Wisconsin 53718
- CMS Provider Number
- 525692
- Inspections on file
- 18
- Latest survey
- October 22, 2025
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Oakwood Village East Health And Rehab Center during CMS and state inspections, most recent first.
A resident with a history of pressure ulcers and decreased mobility was inaccurately assessed as not at risk for pressure injuries, resulting in an inadequate care plan and delayed interventions. Staff inconsistently staged and documented wounds, failed to notify the MD promptly of wound deterioration and infection, and did not follow prescribed wound care orders or provide education on treatment refusals. These failures led to the development of multiple stage 3 or unstageable pressure injuries, including an infected wound.
A resident with a physician order specifying that their Foley catheter should not be manipulated or removed except by urology had the catheter removed by an RN after observing improper drainage and a wet bed. The RN, aware of the order, removed the catheter without first consulting a provider or urology, and only attempted contact after removal. Facility policy and physician orders requiring prior notification and authorization were not followed.
The facility failed to maintain an effective infection prevention and control program, as staff returned to work too soon after GI symptoms, illness tracking forms were incomplete, and infection surveillance documentation for two residents was inaccurate. Additionally, a CNA did not perform required hand hygiene during catheter care, despite facility policy. These deficiencies had the potential to impact all residents.
The facility did not report multiple allegations of abuse and neglect to the state agency as required. Incidents included a resident reporting rough handling and a bruise, another resident experiencing unwanted touching by an LPN, a CNA observing an RN yelling and acting aggressively toward a resident, and other cases of staff refusing care or being rough during care. Despite staff and management acknowledging these as reportable allegations, the facility failed to follow its own policy and regulatory requirements for timely reporting.
Multiple residents and their representatives reported concerns of abuse, neglect, and exploitation, including unwanted touching, rough handling, verbal abuse, and refusal to provide care. The facility did not conduct thorough investigations as required, failed to remove accused staff from resident care during investigations, and did not consistently collect statements or report allegations to the state agency. Residents involved had various medical and cognitive conditions, and the facility did not follow its own policies for investigating and responding to these serious concerns.
The facility did not complete required PASARR Level II screenings for four residents with major mental disorders who remained in the facility beyond the 30-day hospital discharge exemption period. Each resident was admitted with diagnoses such as major depressive disorder and prescribed psychotropic medications, but the necessary follow-up screenings were not performed due to lapses in staff responsibility and oversight.
A resident's advance directive indicating a preference for CPR was not accurately reflected in the electronic medical record, which instead listed a DNR order. Nursing staff confirmed that the resident's code status should match across all records, but the update was not made, resulting in conflicting documentation.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or review antibiotic administration among residents.
A resident's medical record did not contain documentation showing that education about the influenza vaccine was provided or that the resident consented to or declined the vaccine for the most recent season. The required declination form was only completed after surveyors requested it, indicating a lapse in timely documentation as required by facility policy.
The facility failed to maintain a sanitary environment for food service, affecting all residents. Observations showed garbage cans without lids near food prep areas, crumbs in utensil containers, and unclean kitchenettes. Staff did not follow proper food temperature procedures, and a Dietary Aide failed to change gloves or perform hand hygiene while handling food. These deficiencies indicate non-compliance with cleaning and infection control protocols.
The facility failed to manage a COVID-19 outbreak effectively, as it did not recognize a single positive case as an outbreak per CDC guidelines. This led to delayed notification of public health authorities and the Medical Director, and inconsistent documentation of symptoms and testing. The Infection Preventionist acknowledged that outbreak protocols, including masking and testing, should have started earlier, but the absence of the IP and reliance on other staff resulted in inadequate outbreak management.
The facility failed to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications. Four residents were identified as not having adequate monitoring or assessments for their medication use. The facility's staff, including the RN and DON, were interviewed regarding the monitoring of residents. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care.
The facility failed to follow its Antibiotic Stewardship Program, resulting in inappropriate antibiotic prescriptions for several residents with UTIs. Documentation of necessary tests and symptoms was often missing, and criteria for antibiotic use were not consistently met, as confirmed by the Infection Preventionist.
A resident was found with an expired medication on their nightstand, which was not listed in their current orders or care plan. The facility lacked a self-administration assessment for the resident and did not have a Self-Administration policy. The LPN and DON confirmed the medication should not have been in the resident's room, highlighting a lapse in medication management.
The facility failed to develop comprehensive care plans for two residents using psychotropic medications. One resident, with COPD, diabetes, depression, and anxiety, lacked a care plan addressing antidepressants and antianxiety medication. Another resident, with anxiety disorder and Multiple Sclerosis, also lacked a care plan for antidepressant use. The DON acknowledged the need for care plans and was unsure about non-pharmacological interventions. The facility's care plan policy was not provided.
Failure to Prevent and Treat Pressure Injuries According to Standards of Practice
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for the prevention and treatment of pressure injuries in a resident with a history of pressure ulcers and significant risk factors. The resident was inaccurately assessed as not at risk for pressure injury development upon admission, despite a documented history of pressure injuries and decreased mobility. This led to an insufficient care plan that did not adequately address the resident's risk factors or include robust interventions to prevent pressure injuries. The care plan was not updated in a timely manner as the resident's condition changed, and interventions to prevent worsening or new injuries were not implemented promptly. Staff inconsistently staged and documented the resident's wounds, failing to provide detailed descriptions of wound characteristics in weekly assessments. There were discrepancies in wound staging, with some wounds being down-staged contrary to standards of practice, and incomplete documentation regarding the extent of granulation and epithelial tissue. Additionally, wound assessments and documentation were sometimes kept outside the resident's official medical record, leading to gaps in continuity of care. The resident's wounds showed signs of deterioration and infection, but the medical doctor was not notified in a timely manner about these changes. The facility also failed to follow physician orders for wound care and did not provide the resident with information about the risks and benefits when he refused to wear offloading boots, which were prescribed for treatment. Staff did not consistently follow standards of practice during wound care procedures, and treatment orders were not always implemented as prescribed. As a result of these failures, the resident developed multiple stage 3 or unstageable pressure injuries, including an infected wound, which constituted a finding of Immediate Jeopardy.
Foley Catheter Removed Against Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a physician order specifying that their Foley catheter should not be manipulated, flushed, or exchanged, and that only urology should address any issues, had their catheter removed by a registered nurse. The nurse observed that the resident's bed was wet, the catheter was not draining properly, and only 3mL of fluid was present in the balloon upon aspiration. Despite being aware of the explicit order not to manipulate or remove the catheter and to contact urology for any issues, the nurse proceeded to remove the catheter without first consulting a provider or urology. The nurse attempted to contact the primary provider and urology only after the removal had already occurred. Interviews confirmed that the nurse was aware of the standing orders and the facility's policies requiring physician notification and authorization for significant changes in treatment, including catheter removal. The urology clinic confirmed that an afterhours contact was available and that the catheter should not have been removed by facility staff. The Director of Nursing acknowledged that the nurse did not consult with a provider prior to removal and that the event took place before the clinic opened. The facility's failure to follow physician orders and internal protocols led to the deficiency.
Deficient Infection Control Program and Incomplete Surveillance Documentation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in staff illness tracking, resident infection surveillance, and adherence to hand hygiene protocols. One staff member returned to work less than 48 hours after experiencing gastrointestinal symptoms, contrary to CDC guidelines and facility policy, which require exclusion from work for at least 48 hours after symptom resolution. Additionally, the staff illness line list used for infection surveillance was incomplete, with five staff members missing the date of last symptoms, making it difficult to determine appropriate return-to-work timing and to conduct accurate illness tracking. Resident infection surveillance was also found to be deficient. For two residents, the infection line list did not accurately reflect their symptoms or infection details. One resident with a urinary tract infection had missing or incorrect information on the line list, including the onset date, symptoms, and laboratory results, and the infection was not recorded in the appropriate month. Another resident's line list entry did not match the information documented on the McGeer Criteria checklist, with discrepancies in symptoms and infection criteria. These inaccuracies in documentation hindered the facility's ability to conduct effective infection surveillance. Furthermore, staff did not consistently perform appropriate hand hygiene during resident care. During an observation of catheter care, a certified nursing assistant changed gloves four times without performing hand hygiene between glove changes, despite facility policy and standard practice requiring hand hygiene before donning and after removing gloves. The staff member acknowledged the expectation for hand hygiene but did not adhere to it during the observed care. These failures in infection control practices had the potential to affect all residents in the facility.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by state and federal regulations. In five separate cases, allegations of abuse or neglect were either not reported at all or not reported in a timely manner. These included incidents involving unwanted touching by a staff member, verbal and mental abuse, rough handling during care, and refusal to provide care. In each case, the facility's own policy required immediate reporting to the state agency, but this was not followed. One resident with mild cognitive impairment, anxiety, and depression reported that a nurse threw a pill in her mouth and made a derogatory comment, and later reported that a CNA caused a bruise by being rough during care. Both incidents were documented as concerns but were not reported to the state agency as allegations of abuse. Another resident and her representative reported unwanted touching in the vaginal area by an LPN during a skin assessment, which made the resident uncomfortable and fearful. Despite the resident's request for a female caregiver and the clear policy on reporting such allegations, the incident was not reported to the state agency or law enforcement. Additional incidents included a CNA reporting that an RN yelled at a resident, pulled a blanket off without warning, and slammed doors, which was not reported as verbal or mental abuse. Another resident's representative reported that a staff member refused to assist with care, and a resident reported being handled roughly during evening care. In all these cases, staff and management acknowledged during interviews that these were allegations of abuse or neglect that should have been reported, but there was no evidence that the required reports were made to the state agency.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure thorough investigations of multiple allegations of abuse, neglect, and exploitation involving several residents. In several instances, residents or their representatives reported concerns through the facility's grievance process, including unwanted touching by staff, rough handling during care, verbal abuse, and refusal to provide care. Despite these reports, the facility did not conduct comprehensive investigations as required by its own policies. For example, when a resident and her representative reported that an LPN touched her in a private area after she requested a female caregiver, the facility did not remove the staff member from duty pending investigation, nor did it interview other staff or residents who may have had relevant information. Similarly, when a CNA reported that an RN yelled at a resident, pulled off her blanket, and slammed doors, the RN was not suspended, and no further staff or resident interviews were conducted. The facility's policy mandates immediate action to ensure resident safety, including suspension of accused staff and thorough investigation of all allegations, regardless of perceived severity. However, in the reviewed cases, staff members accused of abuse or neglect continued to work with residents during and after the incidents. In several cases, the facility did not collect written statements from witnesses or involved parties, nor did it report the allegations to the state agency as required. Staff interviews revealed uncertainty about what constitutes a thorough investigation, and there was a lack of documentation showing that the facility followed its own procedures for investigating and reporting abuse allegations. Residents involved in these incidents had varying degrees of cognitive impairment and medical complexity, including diagnoses such as mild cognitive impairment, anxiety, depression, chronic obstructive pulmonary disease, and need for assistance with personal care. The failure to investigate allegations thoroughly was consistent across multiple cases, including those involving physical, verbal, and potential sexual abuse, as well as neglect. The facility did not provide evidence of comprehensive investigations, did not consistently remove accused staff from resident care, and did not always report allegations to the appropriate authorities, as required by policy.
Failure to Complete PASARR Level II Screenings for Residents with Major Mental Disorders
Penalty
Summary
The facility failed to complete the required PASARR Level II (Preadmission Screening and Resident Review) screenings for four residents who were admitted with diagnoses of major mental disorders and prescribed psychotropic medications. Each of these residents was initially admitted under a hospital discharge exemption, which allows for a 30-day maximum stay without a Level II screening. However, all four residents remained in the facility beyond the 30-day exemption period, and there was no evidence that the necessary Level II screenings were completed as required by federal regulations and facility policy. For each resident, documentation showed that the Level I PASRR screens identified the presence of a major mental disorder and the use of psychotropic medications. Despite this, and the fact that their stays exceeded the 30-day exemption, the facility did not initiate or complete the Level II screening process. Interviews with social workers and the Assistant Nursing Home Administrator confirmed that the oversight occurred due to a change in staff responsibilities and a lack of follow-up to ensure the PASRR program was maintained during staff transitions. The deficiency was further substantiated by the facility's own policy, which mandates that all new admissions and readmissions be screened for mental disorders or intellectual disabilities per the PASRR process. The failure to complete the Level II screenings was acknowledged by staff during interviews, who indicated that the screenings should have been completed once it was clear the residents would remain in the facility beyond the permitted exemption period.
Failure to Update and Reconcile Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurate and up to date in the electronic medical record. Specifically, one resident's CPR preference form indicated a desire for full code status (to receive CPR), while the electronic medical record and physician orders reflected a DNR (Do Not Resuscitate) status. This discrepancy was identified during a review of the resident's records and confirmed through interviews with nursing staff, who acknowledged that the resident's code status should be consistent across all documentation. The facility's policy requires that information about advance directives be prominently displayed and updated in the medical record, and that changes be communicated to the interdisciplinary team and reflected in the care plan. Despite this, the resident's updated CPR preference was not entered into the electronic medical record, resulting in conflicting documentation. Staff interviews confirmed awareness of the need for consistency between the resident's expressed wishes and the medical record, but the necessary updates were not made at the time the new preference was obtained.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating a lack of oversight regarding antibiotic administration and stewardship within the facility. No specific residents or staff were mentioned in relation to this deficiency, and no details about individual medical histories or conditions were provided.
Failure to Document Influenza Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that a resident's medical record included required documentation regarding influenza vaccination. Specifically, the record did not indicate that the resident or their representative was provided education about the benefits and potential side effects of the influenza immunization, nor did it document whether the resident received the vaccine, declined it, or had a medical contraindication. The facility's policy requires that all residents be offered the influenza vaccine annually and that any refusal be documented and placed in the resident's medical record. In this instance, a resident was admitted to the facility and had documentation of receiving the influenza vaccine in a previous season, but there was no record of vaccination or declination for the most recent influenza season. When surveyors requested documentation, the facility was unable to provide a signed and dated declination form until after the request was made, at which point the resident and staff completed the form. This indicates that the required documentation was not present in the medical record at the time of the surveyor's initial review.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 36 residents. Observations revealed that garbage cans in the kitchenettes and main kitchen lacked lids and were placed near food preparation areas. Additionally, containers holding spatulas and spoons contained crumbs and dried substances. The kitchenettes on the first and second floors had crumbs and dust inside cupboards, and the microwave on the first floor had dried food inside. These conditions indicate a lack of adherence to cleaning protocols, despite management providing cleaning checklists and staff meeting notes outlining cleaning expectations. The facility's staff did not follow proper procedures for taking food temperatures. An Executive Chef was observed using a thermometer incorrectly by placing it in a liquid sanitizer without properly drying it before using it on another food item. The chef also failed to use alcohol wipes as recommended by the facility's policy. This improper practice was acknowledged by the Director of Culinary Services, who indicated that education would be provided to staff regarding the correct procedures. Hand hygiene and glove use were also inadequate. A Dietary Aide was observed handling food and touching various surfaces in the kitchenette without changing gloves or performing hand hygiene. This included touching meal tickets, microwave, plates, and other items before returning to serve food. The Dietary Aide admitted to not changing gloves as required, despite having been educated on proper glove use during orientation. This failure to adhere to infection control policies poses a risk of cross-contamination and highlights a need for improved compliance with hand hygiene standards.
Inadequate COVID-19 Outbreak Management
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, which led to a deficiency in managing a COVID-19 outbreak. The outbreak began when an occupational therapist tested positive for COVID-19, but the facility did not recognize this as an outbreak according to CDC guidelines, which define an outbreak as a single new case of COVID-19 among residents or staff. Consequently, the facility did not notify public health authorities, the Medical Director, or the community in a timely manner, nor did it implement outbreak protocols such as masking and testing immediately. The facility's documentation was inconsistent and incomplete, as evidenced by multiple line lists with differing symptomology for staff members. This inconsistency made it difficult to determine the correct symptomology used for outbreak surveillance and tracking. Additionally, the facility failed to document COVID-19 testing in the resident medical records or staff files, further complicating the tracking and management of the outbreak. The Infection Preventionist (IP) admitted that the outbreak should have been declared earlier and that testing and masking should have started with the first positive case. However, due to the IP's absence on vacation, the outbreak management was left to a medical assistant and supervisors, leading to a lack of proper notification and documentation. The facility's failure to follow CDC recommendations and maintain accurate records contributed to the ineffective management of the COVID-19 outbreak.
Failure to Monitor Residents on Psychogenic Medications
Penalty
Summary
The facility failed to ensure that residents were appropriately monitored and assessed for the use of psychotropic medications. Four residents were identified as not having adequate monitoring or assessments for their medication use. Specifically, one resident was receiving psychogenic medication without adequate monitoring, and another was not receiving proper assessment for their medication. Additionally, the facility did not have a policy in place for sleep assessments, and one resident was not receiving the necessary assessment for their medication. The facility's staff, including the RN and DON, were interviewed regarding the monitoring of residents. The RN reported that they were monitoring for specific conditions, but the facility did not have a policy in place for sleep assessments. The DON reported that they were not sure if the residents were being monitored for side effects, and the facility did not have a policy in place for sleep assessments. The facility's staff were not adequately monitoring the residents, and the facility did not have a policy in place for sleep assessments. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care. The facility's staff were not adequately monitoring the residents, and the facility did not have a policy in place for sleep assessments. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care.
Inappropriate Antibiotic Use Due to Non-Adherence to Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program (ASP) by not ensuring appropriate antibiotic use protocols and monitoring systems were followed for several residents. Specifically, five residents were prescribed antibiotics for urinary tract infections (UTIs) without appropriate indications. The facility's policy requires the use of McGeers and/or Loeb Minimum Criteria to determine the necessity of antibiotic treatment, but this was not consistently applied. For Resident 9, the facility's infection control log indicated a UTI with symptoms of mood swings and irritability, but there was no documentation of a urinalysis (UA) or culture and susceptibility (C&S) to support the antibiotic prescription. Similarly, Resident 23 was prescribed antibiotics despite the absence of documented symptoms and criteria not being met, as confirmed by the Infection Preventionist (IP). Resident 4 was also on antibiotics without documented symptoms or justification, and the prescribed antibiotic was not on the susceptibility list for the identified pathogen. Resident 5 was treated with antibiotics for a UTI, but the facility could not provide the necessary UA and C&S documentation. Lastly, Resident 291 was prescribed antibiotics without documented symptoms or pathogen information, and the IP confirmed that the resident should not have been on antibiotics. These deficiencies highlight a lack of adherence to the facility's ASP and infection control policies, resulting in inappropriate antibiotic use.
Failure to Ensure Appropriate Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for a resident, identified as R10, who was part of a sample of 12 residents. The surveyor observed a medication bottle on R10's nightstand, which R10 identified as an as-needed medication. However, there was no self-administration assessment on file for R10, and the medication was not listed in R10's current orders or care plan. The medication was also expired, and the resident was unable to recall if an assessment had been completed. Further investigation revealed that the facility did not have a Self-Administration policy in place. Interviews with the LPN and the DON confirmed that R10 did not have a self-administration assessment and that the medication should not have been in R10's room. The LPN was unaware of the medication and confirmed it was not ordered for R10, indicating a lapse in medication management and oversight by the facility.
Deficiency in Care Planning for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents regarding their use of psychotropic medications. Resident 11, who was admitted with diagnoses including COPD, Type 2 Diabetes Mellitus, depression, and anxiety, was taking antidepressants buspirone and sertraline daily, as well as the antianxiety medication lorazepam on an as-needed basis. However, the care plan for Resident 11 did not address the use of these medications, the side effects to monitor for, or any non-pharmacological interventions to assist with managing depression or anxiety. Similarly, Resident 32, admitted with generalized anxiety disorder, Multiple Sclerosis, and status-post abdominal surgery, was taking the antidepressant sertraline daily. The care plan for Resident 32 also lacked details on the use of the medication, side effects to monitor, and non-pharmacological interventions for anxiety. During an interview, the Director of Nursing acknowledged that psychotropic medications should be addressed in care plans and expressed uncertainty about the non-pharmacological interventions in place for residents with depression and anxiety. The facility's care plan policy was requested but not provided.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
