Oconto Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oconto, Wisconsin.
- Location
- 101 First St, Oconto, Wisconsin 54153
- CMS Provider Number
- 525670
- Inspections on file
- 31
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Oconto Health And Rehab Center during CMS and state inspections, most recent first.
A resident with facial cellulitis and intact cognition was prescribed oral clindamycin TID after an ER visit, but the facility failed to administer five ordered doses because the medication was not available from the pharmacy and was not in contingency stock. The MAR documented three missed doses on one day and two the next, with the first dose given later that second day. The physician was not notified of the missed doses. During this time, the resident’s facial cellulitis became more painful, leading to repeated hospital transfers where an MRSA cheek abscess with preseptal cellulitis was diagnosed and treated with irrigation, debridement, IV antibiotics, wound packing, and additional oral antibiotics.
A resident with intact cognition and multiple medical conditions reported that a CNA told them they could not be assisted out of bed into a wheelchair if they only wanted to be up for a short period, and this concern was documented as a grievance and reviewed by the DON. The same resident also disclosed giving a tumbler as a gift to the CNA, despite knowing gifts to staff were not allowed, and the CNA ultimately accepted the gift after initially refusing. Although the facility’s abuse, neglect, and exploitation policy required timely reporting of all alleged violations to the State Agency, the NHA and DON acknowledged that these allegations of abuse and exploitation were not reported as required.
A resident with intact cognition and multiple medical conditions reported that a CNA told them they could not get out of bed if they only wanted to be up in a wheelchair for a short period, and also reported having given a tumbler as a gift to the same CNA. The DON documented the grievance as the resident changing their mind about getting up and confirmed that the CNA initially refused but ultimately accepted the gift before returning it. However, the facility did not remove the CNA from resident care during the inquiry, nor did it interview other residents or staff to determine whether similar incidents or additional gift exchanges had occurred, and leadership later acknowledged the investigations were not sufficiently thorough.
Surveyors found that staff did not consistently clean or document cleaning of CPAP/BiPAP/AVAP equipment as ordered and per facility policy for three cognitively intact residents using respiratory support devices. One resident with obstructive sleep apnea and paraplegia had a daily AVAP mask cleaning order, but the treatment record lacked the cleaning order on a key date, and the resident reported mask cleaning was not done and later developed facial cellulitis. Another resident with obesity and obstructive sleep apnea had weekly CPAP cleaning orders but reported the mask was washed only once since admission, and the treatment record showed missed cleanings marked with a code requiring nursing notes that were not present. A third resident with acute and chronic respiratory failure had a daily BiPAP mask cleaning order, was unsure if cleaning occurred, and had at least one day without documented cleaning. An LPN stated nurses were responsible for cleaning and documenting, and the DON confirmed the expected daily mask and weekly tubing cleaning and acknowledged missing documentation.
A resident with a history of dementia and other conditions experienced a worsening skin condition in the groin area, but the facility failed to notify the physician of this change. Despite documentation of care interventions, the lack of communication with the physician was a deficiency in the facility's protocol.
A resident's grievance regarding cleanliness, roommate issues, and shower frequency was not properly documented or resolved by the facility. The resident's guardian reported these concerns, but the facility failed to communicate the investigation's findings or any corrective actions taken. Despite some improvements, the guardian was not informed of interventions to prevent future issues.
A resident with a history of stroke and other conditions reported that a CNA twisted their wrist, causing pain. The incident was reported to staff and the resident's POAHC, but the facility failed to report the allegation to the State Agency or law enforcement as required by their policy. Interviews revealed that staff did not recall or act on the report, leading to a deficiency in reporting the abuse allegation.
A resident reported an allegation of physical abuse by a CNA, which was also communicated to the resident's POAHC and facility staff. However, the facility failed to conduct a thorough investigation as required by their policy, including obtaining statements from involved parties and documenting the incident. The NHA and DON were unaware of the allegation, indicating a deficiency in the facility's response to abuse reports.
Two residents received personal care from an unqualified Hospitality Aide (HA) who was not trained or certified to perform such tasks. The HA assisted with showering, feeding, and transferring, which was outside their job scope. The facility's administration was unaware of these actions.
A resident with an indwelling catheter and wounds did not receive proper infection control measures as CNAs and an RN failed to wear gowns and perform hand hygiene during care. The facility's policy on Enhanced Barrier Precautions was not followed, and gowns were not available near the resident's room. Staff interviews confirmed the oversight.
A resident with moderately impaired cognition refused multiple medications over several days, but the facility failed to notify the resident's physician and corporate Guardian as required by their policy. The medications included those for heart health, hypertension, OCD, depression, and diabetes. The resident's Guardian was unaware of these refusals, and the Director of Nursing acknowledged that staff should have contacted the physician after three refusals.
Two residents in an LTC facility experienced deficiencies in nutritional and hydration care. One resident, with multiple diagnoses, did not have their diet order updated despite a recommendation, leading to weight loss. Another resident, at risk for dehydration, had inconsistent fluid intake documentation. The facility failed to adhere to its policies on nutritional management and hydration monitoring.
Two residents in the facility did not receive their prescribed medications correctly. One resident did not receive calcium 200 mg due to unavailability, and the LPN failed to notify the physician. Another resident received the wrong form of Seroquel XR 50 mg, as the LPN administered a non-extended release version from contingency stock without physician consultation. These actions were against the facility's Medication Administration Policy.
A resident with impaired cognition and a corporate guardian was unable to set up a petty cash fund or RFMS account due to the facility's requirement for direct deposit information, which the guardian could not provide. The facility returned checks sent for the resident, and interviews revealed a lack of process for managing petty cash accounts without direct deposit. The resident expressed a desire for financial independence, but the facility did not accommodate this need.
A resident with a history of diabetes, right hand amputation, and hemiplegia was found with a contracted left hand containing a washcloth, but their care plan lacked interventions to address the contracture. The Nursing Home Administrator confirmed the oversight, and a Hospice RN reported cleaning green slime from the hand. Despite these issues, the care plan remained inadequate, leading to a deficiency.
A resident with significant medical conditions, including diabetes and hemiplegia, experienced a 14.71% weight loss due to the facility's failure to consistently monitor and document nutrition and hydration intake. The resident required one-on-one feeding assistance, but staff did not consistently document meal and fluid intake, and the care plan lacked an intervention for hourly water provision. The facility's limited education efforts and reliance on agency CNAs contributed to the deficiency.
A resident with Huntington's disease and moderate cognitive impairment repeatedly exited the facility unsupervised, posing significant safety risks. The facility failed to implement effective monitoring and intervention strategies, resulting in multiple incidents where the resident was found by police walking on highways and country roads. Despite the resident's refusal to wear a Wanderguard, the facility did not adequately assess or address the resident's risk for elopement.
A resident with Huntington's disease and a history of suicide attempts did not receive appropriate psychiatric follow-up or expedited guardianship at a facility. Despite repeated elopements and unsafe behavior, the facility failed to reassess the resident's needs or make necessary referrals, leading to multiple incidents where the resident was found in dangerous situations. Interviews revealed a lack of timely action and communication regarding the resident's safety and psychiatric needs.
The facility did not implement its abuse policy properly, as it failed to complete an out-of-state background check for the DON and had an incomplete BID form for a Laundry Aide. The BOM, new to the HR role, acknowledged these oversights.
A survey identified multiple infection control deficiencies in an LTC facility, including incomplete infection surveillance records, inadequate hand hygiene by a CNA during resident care, improper storage and use of medical supplies in a resident's room, and failure by an LPN to sanitize a blood pressure cuff between residents. The DON acknowledged these issues, which affected the facility's ability to prevent the transmission of infections.
A resident was observed with medications at their bedside without an accurate self-administration assessment or physician's order reflecting the allowed medications. The care plan lacked details on medication storage, and discrepancies were found between the physician's orders and the medications being self-administered. The resident, with intact cognition, was responsible for their healthcare decisions but was not correctly assessed for self-administration capabilities.
A resident with PTSD, anxiety, and depression was admitted to a facility without a proper PASRR Level II Screen due to an inaccurate Level I Screen. The oversight was confirmed by the facility's MDS coordinator and DON, who acknowledged that the resident's mental health diagnoses should have triggered a Level II Screen.
The facility failed to implement comprehensive care plans for two residents. One resident's care plan did not reflect the need for bed rails, despite the resident's request and the facility's policy requiring a person-centered approach. Another resident's care plan did not include a preference for caregivers of the same gender, despite a history of sexual assault. The Director of Nursing confirmed that these individualized interventions should have been included.
A resident with severe cognitive impairment did not receive routine nail care as required by the facility's policy. Observations revealed the resident's toenails were overgrown and causing discomfort. Staff interviews indicated inconsistencies in nail care practices, with records showing the resident's nails had not been trimmed since admission.
The facility failed to maintain accurate documentation for two residents regarding the use of assistive devices. One resident's care plan did not reflect the use of bed rails, and assessments were not documented. Another resident's cane was removed without proper documentation of the incident or discussion. These deficiencies were identified through observations and interviews, highlighting gaps in the facility's compliance with medical record-keeping standards.
The facility failed to ensure that call lights were within reach for three residents, including one with cerebral infarction and another with chronic pain syndrome. Observations revealed that call lights were either placed out of reach or obstructed, preventing residents from notifying staff for assistance.
A facility failed to administer hydrocortisone to a resident with a history of cerebral infarction and anxiety disorder due to an unaddressed allergy concern, delaying the medication despite physician orders. Additionally, a nurse improperly disposed of a half tablet of buspirone in the garbage instead of using a Drugbuster, as per facility policy, during medication administration for a resident with bipolar disorder.
The facility failed to document, investigate, or resolve grievances for two residents who reported issues with a CNA. One resident was not changed from the previous day, and another was left wet and ignored. The facility did not follow its policy for prompt grievance resolution, and the concerns were not properly documented or investigated.
Failure to Administer Ordered Antibiotic and Notify Physician of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered antibiotic was not administered as prescribed. The resident, who was cognitively intact and responsible for their own healthcare decisions, had a history of left cheek cellulitis. On 12/15/25, nursing documentation described a 4–5 cm swollen, hard, red, warm, and painful area on the resident’s left upper cheek, with a small open center and increasing size and pain over at least three days. The nurse noted there were no prior requests to the physician for advisement, and the resident ultimately requested transfer to the ER that evening. The hospital diagnosed facial cellulitis and prescribed clindamycin 300 mg by mouth three times daily starting 12/16/25. Upon return to the facility, the clindamycin order was not carried out as written due to medication unavailability from the pharmacy. The Medication Administration Record showed that three doses on 12/16/25 and two doses on 12/17/25 were not administered, with the first documented dose given on the PM shift of 12/17/25. The facility did not notify the physician about the missed doses. During this period, the resident’s cellulitis became more painful, leading the resident to request hospital transfer again on 12/17/25 and then again on 12/20/25. Subsequent hospital records documented a MRSA left cheek abscess with preseptal cellulitis requiring irrigation, debridement, wound packing, IV vancomycin, and continued wound care and oral antibiotics after discharge. The DON confirmed that clindamycin was not available in contingency stock, the pharmacy did not deliver it timely, and that the resident missed a total of five doses between 12/16/25 and 12/17/25.
Failure to Report Allegations of Abuse and Exploitation to State Agency
Penalty
Summary
The facility failed to report allegations of abuse and exploitation to the State Agency as required by its Abuse, Neglect and Exploitation policy. The policy, revised 7/1/25, required reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other allegations. A cognitively intact resident, with a BIMS score of 14/15 and diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression, filed a grievance on 2/6/26 stating that a CNA told the resident they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The DON confirmed the resident had reported that the CNA refused to get the resident into the wheelchair during an overnight shift if the resident only wanted to be up for an hour, and that the CNA later stated they had told the resident they might not be able to return in an hour due to assisting other residents. This allegation of abuse was not reported to the State Agency. The facility also did not report an allegation of exploitation involving the same resident and the same CNA. A progress note by the social worker designee documented that the resident had spoken with attorneys and was advised to inform the facility that the resident had given the CNA a tumbler as a gift, and that the resident knew they were not supposed to give gifts to staff. The DON stated that the resident had informed her that the resident purchased a mug for the CNA, who initially refused it multiple times but eventually accepted it due to pressure from the resident. During interviews, both the NHA and DON confirmed that allegations of exploitation should be reported to the State Agency, but this allegation was not reported, resulting in a failure to follow the facility’s own reporting procedures for abuse and exploitation.
Failure to Thoroughly Investigate Allegations of Abuse and Exploitation
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and exploitation involving one cognitively intact resident, R4. R4, who had diagnoses including drug-induced adrenocortical insufficiency, rheumatoid arthritis, anxiety, and depression and a BIMS score of 14/15, filed a grievance stating that a CNA told R4 they could not get out of bed if they only wanted to be up in a wheelchair for an hour. The grievance, reviewed by the DON, was summarized as R4 requesting to get up but changing their mind due to the length of time they would need to remain in the wheelchair, and staff were noted as having been educated on residents’ rights to choose when to be out of bed. However, the facility did not interview other residents or staff to determine if similar incidents had occurred, and the CNA involved was not removed from resident care during the investigation. The NHA and DON later acknowledged that a more thorough investigation of this abuse allegation should have been completed. The facility also did not fully investigate an allegation of potential exploitation when R4 reported having purchased and given a tumbler/mug as a gift to the same CNA. R4 told the social worker designee that attorneys had advised R4 to inform the facility about the gift and acknowledged knowing residents were not supposed to give gifts to staff. The DON confirmed that R4 reported buying a mug for the CNA, that the CNA initially refused it multiple times but ultimately accepted it due to pressure from R4, and that the mug was later returned. Although the facility had documentation that staff were educated on not accepting gifts from residents, there was no evidence that other residents or staff were interviewed to determine whether other gifts had been given and accepted. The NHA and DON agreed that the allegation of exploitation was not investigated thoroughly.
Failure to Clean and Document CPAP/BiPAP/AVAP Equipment per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure CPAP/BiPAP/AVAP equipment was cleaned according to physician orders and the facility’s CPAP/BiPAP Cleaning policy for three residents using respiratory support devices. The policy, revised 6/11/25, required daily cleaning of mask frames after use with CPAP cleaning wipes or soap and water, with proper drying and storage, in accordance with CDC guidelines and manufacturer recommendations. For one resident with paraplegia and obstructive sleep apnea, the medical record showed an AVAP order to clean the mask daily starting 12/14/23, but the December 2025 Treatment Administration Record (TAR) did not contain an order to clean the AVAP mask on 12/4/25. This resident, who was cognitively intact and responsible for their own healthcare decisions, reported that lack of AVAP mask cleaning, along with staff popping a pimple, started irritation on the face, and was diagnosed with facial cellulitis on 12/15/25. A second resident with obesity and obstructive sleep apnea had an order to clean the CPAP mask, headgear, and tubing with mild soap and warm water each morning every Friday for sleep apnea care, starting 12/14/24. This resident, also cognitively intact and responsible for their own healthcare decisions, reported the CPAP mask had been washed only once since admission. The March 2026 TAR showed CPAP cleaning entries marked with a “4” on two dates, indicating a nursing progress note should explain why the treatment was not completed, but no such progress notes were found in the medical record, as confirmed by the DON. A third resident with acute and chronic respiratory failure with hypoxia and an activated POA for healthcare had an order to clean the BiPAP mask once daily starting 2/14/26; this resident was unsure if staff cleaned the mask daily, and the March 2026 TAR lacked documentation of BiPAP cleaning on one date. An LPN stated nurses were responsible for cleaning CPAP/BiPAP/AVAP masks and documenting this in the TAR, and the DON confirmed that masks should be cleaned daily, tubing weekly, and that there were missing dates of completion for all three residents.
Failure to Notify Physician of Resident's Worsening Skin Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident, identified as R7, who was experiencing a worsening skin condition. R7, who had a history of dementia, epilepsy, schizophrenia, anxiety, and traumatic brain injury, was admitted with a moderately impaired cognitive status. The resident's skin condition, specifically redness and pain in the groin and scrotum area, was noted to have worsened over time. Despite this change, the facility did not update R7's physician about the deterioration of the skin condition, which was a requirement according to the facility's Notification of Changes policy. The issue was identified during a survey when the Nursing Home Administrator (NHA) acknowledged that the physician should have been informed of the change in R7's skin condition. Documentation showed that an antifungal powder was ordered for R7's groin area, and the care plan was updated to allow R7 to wash their own peri area. However, the lack of communication with the physician regarding the worsening condition from December to February was a deficiency in the facility's protocol for notifying changes in a resident's condition.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to ensure a grievance was documented, thoroughly investigated, and resolved for a resident, identified as R18, who was part of a sample of 19 residents. The grievance was submitted by R18's court-appointed guardian, GDN-I, who raised concerns about cleanliness, R18's roommate, and the frequency of showers. The grievance form indicated that follow-up occurred the day after the grievance was submitted, but GDN-I reported not being updated on all components of the grievance or how it was resolved. The facility's grievance policy requires that grievances be recorded, logged, and resolved with the resident or their representative being kept informed of the progress. The surveyor's review of the grievance log and interviews with GDN-I and the Nursing Home Administrator (NHA-A) revealed discrepancies in the documentation and communication of the grievance resolution. GDN-I noted that R18 had food on their clothing and surrounding areas, had not received a shower for over a week, and had an inappropriate roommate. Although some actions were taken, such as a room change and scheduling showers, GDN-I was not informed of the investigation's findings or any interventions to prevent future occurrences. NHA-A considered the initial conversation with GDN-I as follow-up but did not provide further documentation or resolution details, leading to the deficiency finding.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R1, to the State Agency as required by their policy. R1, who had a history of cerebrovascular accident, left hemiparesis, dysphagia, and diabetes, reported that a Certified Nursing Assistant (CNA-E) had grabbed and twisted R1's right wrist, causing pain. This incident was reported by R1 to an unidentified staff member and R1's Power of Attorney for Healthcare (POAHC). However, the allegation was not communicated to the State Agency or local law enforcement, as confirmed by the Nursing Home Administrator and Director of Nursing during the survey. The facility's policy mandates immediate investigation and reporting of abuse allegations to the appropriate authorities within specified time frames, particularly within two hours if the allegation involves abuse or results in serious bodily injury. Despite this, the survey revealed that the allegation, which was initially reported during the summer of 2024, was not followed up on, and the POAHC did not receive any updates regarding the investigation. Interviews with staff, including RN-G, who was informed of the incident, showed a lack of recall or action taken, contributing to the deficiency in reporting the abuse allegation as required.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R1, who reported that a Certified Nursing Assistant (CNA-E) had grabbed and twisted their right wrist, causing pain. This incident was reported by R1 and their Power of Attorney for Healthcare (POAHC-J) to the facility staff, including a Registered Nurse (RN-G) and a Licensed Practical Nurse (LPN-H). However, the facility did not conduct a comprehensive investigation as required by their Abuse, Neglect, and Exploitation policy. The policy mandates immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, interviewing all involved parties, and documenting the investigation thoroughly. Despite the report of abuse, the facility did not obtain statements from R1, CNA-E, or other potential witnesses, and there was no follow-up with POAHC-J regarding the allegation. During the survey, the Nursing Home Administrator (NHA-A) and Director of Nursing (DON-B) indicated they were unaware of the allegation. The lack of a thorough investigation and documentation of the incident represents a deficiency in the facility's handling of abuse allegations, as outlined in their policy.
Unqualified Staff Performing Personal Care Tasks
Penalty
Summary
The facility failed to ensure that showers, feeding assistance, and activities of daily living (ADLs) were performed by a qualified person for two residents. Hospitality Aide (HA)-D, who was not a Certified Nursing Assistant (CNA) and had not received the necessary training or competency assessments, assisted residents with personal care tasks such as showering, feeding, and transferring. This was outside the scope of HA-D's job responsibilities, which were limited to providing basic assistance without hands-on care. Resident 15 and Resident 19 were directly affected by this deficiency. Resident 15, who was not cognitively impaired, reported that HA-D completed personal care tasks such as showering and dressing. Similarly, Resident 19, who had a traumatic spinal cord injury with paraplegia and other medical conditions, indicated that HA-D assisted with showering, dressing, and transferring using a Hoyer lift. The Nursing Home Administrator and Director of Nursing were unaware of HA-D's involvement in feeding residents and confirmed that such tasks were beyond HA-D's scope of practice.
Inadequate Infection Control Practices for Resident with Catheter and Wounds
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of Enhanced Barrier Precautions (EBP) and hand hygiene practices for a resident with an indwelling catheter and wounds. On March 11, 2025, Certified Nursing Assistants (CNAs) E and F did not wear gowns while providing personal hygiene and catheter care to the resident, despite the facility's policy requiring gown use during high-contact resident care. Additionally, Registered Nurse (RN) G did not wear a gown or perform hand hygiene between glove changes during wound care for the same resident. The resident, who was not cognitively impaired, had multiple diagnoses including quadriplegia, diabetes, polyneuropathy, and a pressure ulcer, and was on EBP due to an indwelling urinary catheter, ostomy, and wounds. The surveyor observed that there were no gowns available near the resident's room, contrary to the facility's policy. Interviews with the CNAs, RN, Director of Nursing, and Nursing Home Administrator confirmed the failure to adhere to the infection control protocols, acknowledging that gowns should have been worn and hand hygiene should have been performed between glove changes.
Failure to Notify Physician and Guardian of Medication Refusals
Penalty
Summary
The facility failed to notify a physician and a corporate Guardian about a resident's repeated medication refusals, which is a violation of their Medication Administration policy. The policy requires physician notification if two consecutive doses of a vital medication are withheld or refused. The resident, who has moderately impaired cognition and a corporate Guardian for decision-making, refused multiple medications on several occasions in January and February 2025. These medications included those for heart health, hypertension, OCD, depression, personality disorder, GERD, and diabetes mellitus type 2. Despite these refusals, there was no documentation of physician or Guardian notification in the resident's medical record. Interviews conducted by the surveyor revealed that the resident's Guardian was unaware of the medication refusals and that these refusals were not discussed during a care conference. The Director of Nursing confirmed that staff should have contacted the resident's physician after three medication refusals, indicating a lapse in following the facility's policy. This oversight in communication and documentation led to the deficiency identified by the surveyors.
Deficiencies in Nutritional and Hydration Care for Two Residents
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for two residents, R3 and R1, leading to deficiencies in maintaining their health. R3, who had multiple diagnoses including dysphagia and moderate intellectual disability, was on a mechanical soft diet with ground meat. Despite a recommendation from Speech Therapy to upgrade R3's diet to cut-up meat, the diet order was not changed, and a swallow study was not completed. Additionally, R3's meal intakes were inconsistently documented, contributing to a 7.3% weight loss over three months. R3's guardian and family were not informed about the dietary restrictions, and there was a lack of communication and follow-up regarding the necessary dietary adjustments. R1, who had conditions including diabetes and hemiplegia, was at risk for dehydration and required total assistance with eating. The facility's staff did not consistently document or monitor R1's fluid intake, with 56.78% of shifts missing documentation. Although staff were observed offering fluids to R1, the lack of documentation made it unclear whether R1 was receiving adequate hydration. The Director of Nursing acknowledged the missing documentation and the expectation for CNAs to record fluid intake every shift. The facility's policies on nutritional management and hydration monitoring were not adhered to, resulting in inadequate care for R3 and R1. The failure to update R3's diet order and complete a swallow study, along with the inconsistent documentation of meal and fluid intake, highlighted significant lapses in the facility's care processes. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyor.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, R5 and R6, as observed during a survey. R5 did not receive the prescribed calcium 200 mg during the morning medication pass because the medication was unavailable in the facility. The Licensed Practical Nurse (LPN) responsible for administering the medication did not notify R5's physician about the missed dose, which was against the facility's Medication Administration Policy. R5 had multiple diagnoses, including a disorder of bone and chronic systolic heart failure, which necessitated the calcium supplement. R6, who had diagnoses including schizoaffective disorder and COPD, did not receive the correct form of Seroquel XR 50 mg as ordered. Instead, the LPN administered two 25 mg tablets of quetiapine, which was not the extended-release form required. This substitution was made from the facility's contingency stock without consulting the physician, resulting in a medication error. The Director of Nursing confirmed that the LPN administered an incorrect medication to R6, which was a deviation from the prescribed treatment plan.
Failure to Establish Resident Financial Account
Penalty
Summary
The facility failed to honor a resident's right to manage their financial affairs by not allowing a resident, who had a corporate guardian, to set up a petty cash fund or Resident Fund Management Service (RFMS) account. The resident, identified as R2, was admitted with diagnoses including dementia, schizophrenia, and anxiety, and had a severely impaired cognition score. Despite requests from R2's corporate guardian to establish a resident account, the facility required direct deposit account information, which the guardian could not provide due to organizational restrictions. As a result, the facility returned two checks sent by the guardian for R2, as the RFMS authorization agreement was not signed. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) revealed that the facility did not have a process to manage petty cash accounts without a direct deposit setup. The BOM indicated that it was not the facility's responsibility to manage residents' finances without legal authority, and the NHA confirmed that the facility should handle funds if requested by residents. The resident expressed a desire to have access to money to make purchases like other residents but was unsure how to establish an account. The facility's inability to accommodate the resident's financial management needs led to the deficiency.
Failure to Address Resident's Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care to prevent further decrease in range of motion for a resident with a contracted left hand. The resident, who had a history of diabetes mellitus, right hand amputation, and hemiplegia following a stroke, was observed with a contracted left hand containing a rolled-up washcloth. The resident's care plan did not include interventions to address the contracture, which was confirmed by the Nursing Home Administrator. The administrator acknowledged that the care plan should have included measures to prevent the worsening of the contracture and mentioned that therapy staff were in the process of finding a suitable piece of foam for the resident's hand. Additionally, a Hospice RN reported that a Hospice CNA had to clean green slime from the resident's left hand, which had a noticeable odor. The Hospice RN assessed the hand and found no redness or open wounds but placed a washcloth in the hand. The facility staff were informed of this issue during a care conference. Despite these observations and reports, the resident's care plan remained inadequate in addressing the contracture, leading to the deficiency noted by the surveyor.
Failure to Monitor and Document Nutrition and Hydration Intake
Penalty
Summary
The facility failed to consistently monitor and document the nutrition and hydration intake for a resident who required total assistance with eating due to significant medical conditions, including diabetes mellitus, amputation of the right hand, and hemiplegia following a stroke. The resident had orders for one-on-one feeding assistance and documentation of meal and fluid intake at each meal, which were not consistently followed. The resident's care plan was also not updated to include an intervention for staff to offer and provide water every hour, despite a significant weight loss of 14.71% over several months. Observations and interviews revealed that the facility's staff did not consistently document the resident's meal and fluid intake, with numerous missing entries noted in the Treatment Administration Records over three months. The facility's Nursing Home Administrator acknowledged the expectation for CNAs to document fluid intake every shift and confirmed that missing documentation implied the resident did not receive fluids. Additionally, the facility's education efforts to ensure the resident was fed and provided water were limited, with only a few CNAs receiving the training, and agency staff were not informed of the necessary interventions due to the care plan's lack of updates.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, identified as R1, from repeatedly exiting the facility without signing out, which led to a finding of Immediate Jeopardy. R1, who had Huntington's disease, diabetes mellitus, chronic kidney disease, and depression, exhibited moderate cognitive impairment and decreased safety awareness. Despite these conditions, R1 was able to leave the facility multiple times, often found by police walking on highways and country roads, posing significant safety risks. The facility's policy on elopements and wandering residents was not effectively implemented for R1. R1's care plan included interventions such as arranging transportation for appointments and reminding R1 to sign out, but these measures were insufficient. R1's medical record indicated a low risk for elopement, and R1 was not included in the Wander Communication Binder, which was a critical oversight given R1's history of wandering and elopement. Staff interviews revealed a lack of consistent monitoring and intervention strategies for R1. The facility did not have a system to track R1's whereabouts, and staff often relied on police to return R1 to the facility. Despite R1's refusal to wear a Wanderguard, the facility did not explore alternative safety measures or adequately assess R1's risk for elopement, leading to repeated incidents of R1 leaving the facility unsupervised.
Removal Plan
- Educate residents who leave the facility independently to sign out with their location and when they will return.
- Offer R1 transportation to locations not within walking distance.
- Update the Wander Communication Binder.
- Initiate elopement drills.
- Reeducate staff on the elopement/wander policy, including care planning and identification of potential elopement risks.
Failure to Provide Medically-Related Social Services for Resident with Psychiatric Needs
Penalty
Summary
The facility failed to provide appropriate medically-related social services for a resident with a history of suicide attempts and psychiatric needs. The resident, who had Huntington's disease, diabetes mellitus, chronic kidney disease, and depression, was admitted to the facility without a follow-up on psychiatric services after being discharged from the hospital. The resident exhibited unsafe behaviors, such as leaving the facility multiple times and refusing medications, yet the facility did not expedite the guardianship process or ensure the continuation of psychiatric care. The facility's policy on elopements and wandering residents was not adequately followed. Despite the resident's repeated elopements and unsafe behavior, the facility did not reassess the resident's needs or make necessary referrals for psychiatric consultations. The resident's care plan indicated a risk for self-inflicted injury and decreased safety awareness, but the facility's response was insufficient, as evidenced by multiple incidents where the resident left the facility unsupervised and was found in potentially dangerous situations. Interviews with staff and external agencies revealed a lack of timely action and communication regarding the resident's safety and psychiatric needs. The facility did not seek guidance from Adult Protective Services on how to keep the resident safe while awaiting guardianship, nor did they contact the State Ombudsman for advice. The Social Services Designee admitted to not following up on the psychiatric concerns listed in the hospital discharge summary, contributing to the deficiency in care provided to the resident.
Incomplete Background Checks for Staff
Penalty
Summary
The facility failed to implement its abuse policy effectively, as evidenced by incomplete background checks for two employees. The Director of Nursing (DON)-B, who was hired in 2020, had a four-year Background Information Disclosure (BID) form completed in 2024, which indicated that the DON had resided outside the state in the past three years. However, the facility did not conduct the required out-of-state background check for DON-B. This oversight was identified during a review of the DON's background check information by a surveyor. Additionally, the facility did not have a fully completed BID form for Laundry Aide (LA)-C, who was hired in 2024. The surveyor found that pages 2 and 3 of LA-C's BID form were missing. The Business Office Manager (BOM)-D, who was new to the Human Resources role, acknowledged the missing documentation and the requirement for a complete BID form. BOM-D also confirmed the necessity of an out-of-state background check for employees who have lived outside the state within the past three years.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. The infection surveillance line list for staff was incomplete, lacking critical information such as the well date for HR-G and COVID-19 test results for CNA-F. The Director of Nursing, who also served as the Infection Preventionist, acknowledged these omissions and confirmed that the missing information was an oversight. Inadequate hand hygiene practices were observed during the provision of care for a resident with a urinary catheter. CNA-I failed to perform hand hygiene between glove changes while providing perineal and catheter care, despite the facility's policy requiring such practices. Additionally, CNA-I did not wear the appropriate personal protective equipment (PPE) as indicated by the Enhanced Barrier Precautions (EBP) policy, which was confirmed by both the CNA and the Director of Nursing. The survey also revealed improper storage and use of medical supplies in a resident's room, where used PPE and medical items were found. The resident confirmed that staff used personal supplies for care, contrary to facility policy. Furthermore, LPN-J did not sanitize a blood pressure cuff between uses on two residents, which was not in line with the facility's equipment protocol. The Director of Nursing verified that staff were expected to sanitize equipment between residents unless it was disposable.
Deficiency in Self-Administration of Medication Assessment
Penalty
Summary
The facility failed to ensure a proper self-administration of medication assessment for a resident, identified as R11, who was observed with medication at their bedside. The assessment and physician's order did not accurately reflect the medications R11 was allowed to self-administer. Additionally, R11's care plan did not specify how the medications were to be stored and secured in their room. R11, who had intact cognition and was responsible for their healthcare decisions, was observed to self-administer eye drops, nasal spray, and inhaled medications, but the care plan did not indicate the storage arrangements for these medications. The resident's medical record showed discrepancies between the physician's orders and the medications R11 was self-administering. The Medication Administration Record (MAR) did not include orders for nebulizer treatments, which were mentioned in the physician's order. Furthermore, the Self-Administration of Medication Evaluation indicated that R11 could not correctly administer eye drops or ointments, yet they were self-administering these medications. Interviews with the Director of Nursing confirmed that the care plan should have included storage details and that the physician's order should have been for an albuterol inhaler instead of a nebulizer treatment.
Failure to Complete Accurate PASRR Screening for Resident
Penalty
Summary
The facility failed to meet the Pre-Admission Screen and Resident Review (PASRR) requirements for a resident, identified as R7, who was admitted with diagnoses including post-traumatic stress disorder (PTSD), anxiety, and depression. Despite these diagnoses, R7's PASRR Level I Screen inaccurately indicated that the resident was not suspected of having a serious mental illness and did not have a current diagnosis of mental illness. This error led to the omission of a necessary PASRR Level II Screen, which should have been completed to evaluate the need for specialized services and appropriate nursing facility placement. The deficiency was identified during a surveyor's review of R7's medical records and interviews with facility staff. The Minimum Data Set (MDS) assessment for R7 showed moderate cognitive impairment, and previous medical records indicated a history of mental health issues, including suicidal ideation. The facility's MDS coordinator and Director of Nursing acknowledged the oversight, confirming that the PASRR Level I Screen should have reflected R7's mental health diagnoses, necessitating a Level II Screen. This oversight highlights a failure in the facility's adherence to PASRR guidelines, impacting the resident's care assessment process.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to ensure comprehensive resident-centered care plans were implemented for two residents, R7 and R15. For R7, the care plan did not indicate the need for a bed rail, despite the resident expressing a need for bilateral bed rails to assist with positioning and mobility. The facility's policy on bed rails requires a person-centered approach, but R7's care plan lacked a physician's order for bed rail use. Interviews with staff revealed confusion about R7's need for bed rails, with conflicting statements about whether R7 wanted or needed them. The Director of Nursing confirmed that an assessment should have been completed to determine the necessity of bed rails for R7. For R15, the care plan failed to address the resident's request for no caregivers of the opposite gender, despite R15's history of sexual assault. R15 expressed discomfort with a specific CNA, but the care plan did not reflect this preference. The Director of Nursing acknowledged that the individualized intervention should have been included in R15's care plan, especially given the resident's traumatic history. The oversight in both cases highlights a lack of adherence to the facility's policies and procedures for developing and implementing comprehensive care plans.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as R21, who required assistance with activities of daily living. R21 had severe cognitive impairment and was dependent on staff for all care. Despite the facility's policy that routine nail care, including trimming and filing, should be provided regularly, R21's toenails were observed to be thick, discolored, overgrown, and curling, with a substance underneath. This condition was noted during observations on two separate occasions, and R21 reported experiencing pain in the big toe. Interviews with facility staff revealed inconsistencies in the provision of nail care. A Certified Nursing Assistant (CNA) stated that nail care was part of daily grooming, while the Assistant Director of Nursing (ADON) indicated that nail care was scheduled weekly on shower days. However, records showed that R21's toenails had not been trimmed since admission. The Director of Nursing (DON) confirmed the need for trimming and acknowledged that nail care should coincide with weekly showers, highlighting a lapse in adherence to the facility's nail care policy.
Deficiencies in Documentation for Assistive Devices
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records of two residents, R7 and R10. For R7, the deficiency involved the use of bed rails. R7, who has Parkinson's disease and moderate cognitive impairment, was observed with a bed rail on the left side of the bed, despite the care plan not indicating the need for bed rails. The care plan history showed that bed rails were previously used but discontinued. The Registered Nurse (RN) stated that R7 was not reapproved for bed rail use and admitted that the assessment regarding the need for bed rails was not documented in R7's medical record. The Director of Rehab confirmed that therapy notes did not specifically address bed rail use, and the Director of Nursing acknowledged that an assessment should have been documented. For R10, the deficiency involved the removal of a cane without proper documentation. R10, who has intact cognition and a history of cerebral infarction, reported that a cane belonging to R10's grandfather was taken away by staff. The Director of Nursing stated that the cane was removed because R10 had swung it at staff, and it was kept in the office until deemed safe for R10 to use. However, this discussion and the removal of the cane were not documented in R10's medical record. A progress note indicated that R10 had previously threatened staff with the cane, but there was no documentation of the specific incident leading to the cane's removal. The lack of documentation for both residents highlights a failure in maintaining accurate medical records and ensuring that assessments and decisions regarding assistive devices are properly recorded. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyor, revealing gaps in the facility's compliance with professional standards for medical record-keeping.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating their needs and preferences. Resident 1, who had cerebral infarction with left-sided paralysis and a below-elbow amputation of the right arm, was observed without a call light within reach. Despite having a soft-touch call light near the left elbow, Resident 1 was unable to use it due to the paralysis and was dependent on staff for all activities of daily living. The care plan did not specify the type or placement of the call light needed to accommodate Resident 1's physical limitations. Similarly, Resident 7, with diagnoses including congestive heart failure and diabetes mellitus, was found unable to reach the call light, which was placed on the bed while the resident was seated in a chair several feet away. Resident 8, who had chronic pain syndrome and anxiety disorder, also could not reach the call light due to its placement on the bed with a bedside table obstructing access. These observations indicate a failure to reasonably accommodate the residents' needs for assistance, as the call lights were not accessible, preventing them from notifying staff when help was needed.
Medication Administration and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the accurate administration of medication for one resident and did not provide safe handling of drugs for another. One resident, who had a history of cerebral infarction, left-sided paralysis, and anxiety disorder, did not receive multiple doses of hydrocortisone as ordered by their physician. Despite a hospital discharge summary indicating the need for hydrocortisone, the facility delayed administering the medication due to an unaddressed allergy concern. The Director of Nursing acknowledged that the endocrinology orders should have been processed earlier and that there was a lack of timely transcription and clarification of physician orders. Another resident, diagnosed with bipolar disorder and an unspecified mental disorder, was observed during medication administration where a registered nurse improperly disposed of a half tablet of buspirone in the garbage. The nurse had to cut a 10 mg tablet in half to achieve the prescribed 15 mg dose, but discarded the unused half inappropriately. The nurse also failed to use a half pill that was taped in a medication card slot because they could not verify its identity. This improper disposal was contrary to the facility's policy, which requires unused medications to be disposed of in a Drugbuster or similar system.
Failure to Document and Investigate Grievances
Penalty
Summary
The facility failed to thoroughly document, investigate, or resolve grievances for two residents. One resident reported that a Certified Nursing Assistant (CNA) did not change their clothing from the previous day, and another resident reported being left wet and ignored by the same CNA. Despite these grievances, the facility did not document or investigate these concerns adequately. The facility's grievance file did not contain records of these grievances, and there was no indication that the issues were resolved. The facility's policy requires prompt efforts to resolve grievances, including documentation and investigation, which were not followed in these cases. The medical records of the two residents involved indicated that one had severely impaired cognition and an activated Power of Attorney, while the other had moderate cognitive impairment and a Guardian for decision-making. Interviews with the residents and staff revealed that the concerns were known but not properly documented or investigated. The Director of Nursing and Nursing Home Administrator acknowledged the lack of documentation and investigation, and it was noted that the CNA involved had received education on proper techniques but was still on their last chance due to ongoing issues.
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.
