Odd Fellow Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Green Bay, Wisconsin.
- Location
- 1229 S Jackson St, Green Bay, Wisconsin 54301
- CMS Provider Number
- 525559
- Inspections on file
- 24
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Odd Fellow Home during CMS and state inspections, most recent first.
A resident with post-hip arthroplasty, osteoarthritis, and atrial fibrillation had a clarified order for Eliquis to be given at 2.5 mg BID for one week, then increased to 5 mg BID. Although the clarification was documented and the family was informed, staff continued to administer 2.5 mg BID for an additional day, and the MAR showed the 5 mg BID dose was not started until the following day. This discrepancy, attributed by the NHA to a possible transcription error, resulted in two incorrect Eliquis doses and was not consistent with the facility’s medication administration policy requiring adherence to prescriber orders.
The facility did not report two separate allegations of abuse involving two residents to the State Agency as required. In one case, a resident's abuse-related fall investigation was not submitted within the mandated timeframe, and in another, a resident's report of rough handling by a CNA was handled as a grievance but not reported to the SA.
Two residents' abuse allegations were not thoroughly investigated, as required by facility policy. In one case, a resident's fall determined to be abuse lacked statements from the involved CNA and LPN, and staff education did not match the resident's care plan. In another case, a resident reported being manhandled by a CNA, but the investigation was incomplete, missing root cause analysis, interviews, and documentation of staff education.
A resident with multiple medical conditions, including epilepsy, did not receive scheduled AM and PM medications within the required time frame on several occasions. Facility policy requires medications to be administered within one hour of the prescribed time, but MAR review and staff interviews confirmed repeated late administration, and the resident reported ongoing concerns about medication delays.
A resident with severe cognitive impairment, muscle weakness, and a history of repeated falls did not consistently receive prescribed fall prevention interventions, including 15-minute safety checks and grip strips at the bedside. Staff failed to complete safety checks for several hours, during which the resident experienced an unwitnessed fall with injury. Observations and staff interviews confirmed that interventions were not reliably implemented or documented, despite facility policy and the resident's high risk status.
The facility did not have a qualified IP overseeing the infection prevention and control program, as neither the interim IP nor the DON had completed required specialized training. During this period, staff returned to work before meeting CDC recommendations after COVID-19 or GI illness, and the facility lacked policies specifying IP training requirements or hours needed for the role.
Surveyors found that medications and biologicals were not consistently labeled, dated, or stored according to policy. Multiple medications, including inhalers, insulin, and eye drops, were found without open dates or labels, and expired medications and supplies were present in storage areas and on medication carts. Staff, including LPNs and the DON, confirmed these deficiencies during interviews, acknowledging that medications should be dated when opened and expired items should be removed.
Multiple staff failed to use appropriate PPE and follow infection control protocols during care of residents on enhanced barrier precautions, including wound care and equipment sanitation. Additionally, staff returned to work after COVID-19 or GI illness earlier than CDC and state guidelines recommend, with incomplete documentation of symptom resolution.
Three residents received antibiotics without meeting McGeer's criteria for infection, and prescribers were not notified of the lack of qualifying signs or symptoms. The facility did not follow its own antibiotic stewardship policies, resulting in inappropriate antibiotic use for urinary, skin, and respiratory infections.
Two residents with suspected serious mental illness were granted 30-day hospital exemptions on their PASRR Level I Screens, but the facility did not submit the required PASRR Level II Screens after the exemptions expired. One resident had anxiety disorder and was not cognitively impaired, while the other had multiple mental health diagnoses and moderate cognitive impairment. The Admissions Coordinator confirmed the oversight.
A resident receiving hemodialysis was not consistently monitored for bruit/thrill as required by facility policy, and there was a lack of ongoing communication between facility staff and the dialysis center. Staff interviews revealed that daily monitoring was not documented, and there was confusion about what information was exchanged with the dialysis center, resulting in incomplete records and missing aftercare instructions.
A nurse administered Senna-Plus, a combination laxative, instead of the prescribed Senna to a resident during a medication pass. Facility policy requires staff to verify medications against prescriber orders, but this step was not followed, resulting in the resident receiving the incorrect medication.
The facility failed to update care plans for three residents regarding the use of Hoyer slings, which were left under residents in Geri chairs and wheelchairs, contrary to facility policy. Despite the policy requiring sling removal, staff routinely left them in place, and care plans lacked necessary updates. Observations and interviews confirmed this practice, with residents reporting no discomfort, but the facility's policy was not followed.
A resident with hemiplegia and an acquired absence of the right leg was left hanging in a lift due to a dead battery during a transfer. Staff interviews revealed that lift batteries often died mid-transfer, and staff did not consistently check battery life. The facility had ordered new batteries, but only one was observed in the charger. The Nursing Home Administrator confirmed that staff should use a manual release to lower residents if a battery dies, but this was not done, resulting in the resident being left suspended.
Two residents with indwelling catheters had their catheter drainage bags improperly placed in contact with the floor, contrary to the facility's policy. One resident's bag was on the floor due to the bed's position, while another's bag was dragging on the floor from their wheelchair. Staff confirmed the improper placement, highlighting a lapse in infection control procedures.
A resident with type 2 diabetes on a CCHO diet received a full piece of cake instead of the prescribed half piece. The dietary staff provided the larger portion based on the resident's preference, despite the meal ticket indicating a smaller serving. The facility lacked a policy to ensure adherence to prescribed diets, leading to this inconsistency.
A resident on Enhanced Barrier Precautions did not receive proper infection control measures as staff failed to wear PPE during high-contact care and did not disinfect equipment after use. Despite the resident's significant medical history, including severe sepsis and open wounds, staff did not adhere to the facility's infection control policies.
The facility failed to timely report and investigate an altercation between two residents, one with intact cognition and another with severe cognitive impairment. The incident was not reported to administration promptly, leading to a delay in notifying the State Agency. Additionally, there was no proof of education for certain staff on duty during the incident, indicating a lapse in staff training on reporting requirements.
The facility failed to ensure proper disposal of garbage and refuse in outside dumpsters. During a kitchen tour, three dumpsters were found with open lids and garbage on the ground. The Dietary Manager acknowledged the issue but did not take immediate action to remove the garbage.
The facility failed to honor the meal preferences of six residents, providing meals that did not match dietary plans or preferences. Staff made assumptions about residents' choices without consulting them or their power of attorney for healthcare.
The facility failed to provide timely written transfer notices to three residents and did not notify the State Long-Term Care Ombudsman of these transfers. The residents were transferred to the hospital for various medical reasons, but the required documentation and notifications were not completed as per the facility's policy.
The facility failed to provide three residents with written information regarding the bed hold policy when they were transferred to the hospital. This deficiency was confirmed by the Assistant Nursing Home Administrator and the Nursing Home Administrator, who indicated that nurses are expected to provide this information but did not do so in these cases.
The facility failed to ensure resident safety and proper fall management by using defective equipment, not completing fall assessments, and not updating care plans with new interventions. Despite warnings, a lift with broken brakes and a defective sling was used, and neurochecks were not completed as required.
A resident with obstructive sleep apnea was provided with CPAP therapy without a physician's order, and the need for and use of CPAP therapy was not included in the care plan. The facility's policies for CPAP therapy and infection prevention were not followed, as evidenced by the lack of labeling on the CPAP machine's tubing and inconsistent staff education on the CPAP mask/machine.
The facility failed to ensure proper monitoring of a high-risk medication for a resident with diabetes mellitus. The resident's care plan lacked interventions to monitor for hypoglycemia and hyperglycemia, despite having physician orders for both short-acting and long-acting insulin. The deficiency was confirmed through a medical record review and an interview with the DON.
Failure to Accurately Transcribe and Implement Eliquis Dose Change
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate medication administration for one resident when staff did not follow the prescriber's clarified order for Eliquis dosing. The resident was admitted with diagnoses including post-hip arthroplasty, osteoarthritis, atrial fibrillation, and panic disorder, and had an MDS BIMS score of 15/15 indicating intact cognition. Hospital discharge paperwork ordered Eliquis 5 mg twice daily for DVT prevention, with instructions to give 2.5 mg twice daily for the first seven days post-operatively. A subsequent physician communication on 12/23/25 clarified that the resident should receive Eliquis 2.5 mg twice daily through 12/25/25 and 5 mg twice daily starting on 12/26/25, and a nursing note documented that the order was changed accordingly and the family was updated. Despite this clarification and documentation, the December MAR showed that the resident continued to receive Eliquis 2.5 mg twice daily from 12/19/25 through 12/26/25, totaling eight days at the lower dose, and the 5 mg twice daily dose was not started until 12/27/25. This resulted in the resident receiving two incorrect doses of Eliquis on 12/26/25, contrary to the prescriber's order and the facility's Administering Medications policy, which requires medications to be administered in accordance with prescribers' orders. During interview, the NHA confirmed that the Eliquis dose should have been increased on 12/26/25 and acknowledged that a transcription error may have occurred when the order was entered.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency (SA) for two residents as required by policy and federal regulations. In the first instance, a resident with multiple diagnoses including dementia, Huntington's disease, and repeated falls experienced a witnessed fall. The Interdisciplinary Team determined that abuse had occurred based on the LPN's progress note. While the initial report was submitted to the SA on the day of the incident, the required 5-day investigation report was not submitted within the mandated timeframe, as the Nursing Home Administrator delayed submission while waiting for an additional staff statement. In the second instance, another resident with intact cognition and a history of congestive heart failure, respiratory failure, and falls reported to staff that a CNA was abusive during care, describing rough handling and feeling unsafe. The facility initiated a grievance form and provided staff education, but did not report the abuse allegation to the SA as required. The Nursing Home Administrator later verified that this allegation should have been reported.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents. In the first case, a resident with multiple diagnoses including dementia, Huntington's disease, and repeated falls, experienced a witnessed fall. The facility determined that abuse had occurred based on a progress note from an LPN. However, the investigation was incomplete as it did not include statements from the involved CNA or LPN. Additionally, the staff education provided after the incident was inaccurate, as it did not reflect the resident's care plan requirements for transfer assistance, and only a fraction of employees signed the education documentation. In the second case, another resident with intact cognition and a history of falls and other medical conditions reported that a CNA was abusive, describing being manhandled and treated rudely during care. The grievance was documented, but the investigation did not follow facility policy, as it lacked immediate action, root cause analysis, interviews with other potentially affected residents, and witness statements from involved staff. There was also no documentation of staff education signatures or further investigative records related to this allegation. Both incidents demonstrate that the facility did not adhere to its own policies regarding the immediate and thorough investigation of abuse allegations. Required investigative steps, such as obtaining statements from all involved parties and ensuring accurate staff education, were not completed, resulting in deficiencies in the facility's response to reported abuse.
Failure to Administer Medications Timely per Physician Orders
Penalty
Summary
A deficiency was identified when a resident's medications were not administered in accordance with physician orders and facility policy. The facility's policy requires medications to be administered within one hour of the prescribed time unless otherwise specified. Record review and staff interviews revealed that a resident, who had diagnoses including osteomyelitis, epilepsy, peripheral vascular disease, depression, and osteoarthritis, experienced multiple late administrations of both morning and evening medications. The resident, who was cognitively intact and their own decision maker, reported to the surveyor that their medications, including antiepileptic drugs, were late most days and specifically had not been received by the expected time on the day of the survey. Review of the Medication Administration Record (MAR) showed that the resident's scheduled 8:00 AM medications were administered late on at least seven occasions, with administration times ranging from 9:10 AM to 10:06 AM. Additionally, an evening medication scheduled for 8:00 PM was administered at 11:04 PM on one occasion. Staff interviews confirmed that the nurse was running late with the medication pass and that the resident had expressed concerns about the timeliness of medication administration. The Nursing Home Administrator also acknowledged the facility's policy regarding the one-hour window for medication administration.
Failure to Consistently Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to consistently implement fall prevention interventions for a resident assessed as high risk for falls. The resident had a history of repeated falls, cognitive impairment, muscle weakness, and required substantial assistance with mobility and activities of daily living. The care plan included interventions such as fifteen-minute safety checks while sleeping and grip strips on the floor near the bed, but these were not reliably carried out. Specifically, safety checks were not completed for over three hours on one occasion, during which the resident experienced an unwitnessed fall resulting in head lacerations. Additionally, grip strips were not present at the bedside during observations, and staff confirmed these were not placed after the resident changed rooms. Staff interviews revealed inconsistent implementation and documentation of the prescribed interventions. The DON and ADON acknowledged that grip strips were not installed in the new room and that 15-minute safety checks were not always performed or properly documented. The ADON also indicated that the checks were not consistently listed as care plan interventions and that CNAs did not always follow the intended protocols. Observations further showed the resident was at risk while seated in a Broda chair, with poor posture and sliding down, requiring staff assistance. The facility's own policy required staff to identify and implement interventions based on the resident's specific risks and to monitor and adjust these interventions as needed. Despite the resident's high fall risk and documented history of falls, the facility did not ensure that the care plan interventions were consistently in place or that staff adhered to the established protocols, leading to preventable lapses in supervision and safety.
Failure to Ensure Qualified Infection Preventionist and Adequate Infection Control Program
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was responsible for the infection prevention and control program, as required by CMS regulations. After the previous IP left unexpectedly, the facility assigned IP duties to IP-C and the DON, but neither had completed the required specialized training in infection prevention and control. IP-C had started the CDC IP training modules but had only completed 10 out of 24 modules, while the DON had not begun any IP training. The newly hired IP had just started training and was not yet qualified. The facility also lacked an infection prevention and control policy that described the IP's training requirements or specified the number of hours needed for the IP role. Surveyor interviews and record reviews revealed that, during this period, there were multiple instances where staff returned to work before meeting CDC recommendations following COVID-19 or gastrointestinal illness. Additionally, the facility assessment did not specify the required hours for the IP position, and there were gaps in the infection prevention process due to the absence of a trained IP. The facility did not have a trained IP available to train the new IP, further contributing to deficiencies in the infection prevention and control program.
Medication Labeling, Dating, and Storage Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure medications and biologicals were properly labeled, dated, and stored according to professional standards and facility policy. During observations, multiple instances were noted where medications, including inhalers, insulin, eye drops, and supplements, lacked open dates or were left unlabeled. For example, an LPN confirmed that a Med Pass 2.0 supplement on the medication cart was not dated when opened, and an RN acknowledged leaving medication unattended on top of a medication cart in the hallway. Additionally, several residents' medications, such as inhalers and insulin, were found without required open dates, despite pharmacy labels specifying expiration periods after opening. Further inspection of medication storage areas revealed the presence of expired and undated medications and medical supplies. Surveyors found numerous expired items, including vacutainer devices, lubricating jelly packets, blood tubes, syringes, and skin repair cream, as well as undated and open medication packages for several residents. Staff interviews confirmed that these items were expired and should have been removed from storage. The facility's policies require that expired or discontinued medications be returned or destroyed and that all medication storage compartments remain locked and not left unattended. Additional deficiencies were observed on medication carts, where open, unlabeled, and undated medications and supplies were found, including inhalers, nasal sprays, eye drops, and other treatments. Staff interviews with LPNs and the DON confirmed that medications such as eye drops, inhalers, and nebulizer packets should be dated when opened and that expired items should be disposed of. Despite the facility's stated practice of conducting audits and checking dates before use, these lapses in medication management were directly observed during the survey.
Failure to Implement and Enforce Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. Several staff members did not use appropriate personal protective equipment (PPE) when providing care to residents on enhanced barrier precautions (EBP), including during transfers, hygiene, and wound care for a resident with chronic diabetic wounds. The resident's room initially lacked EBP signage, and staff were observed assisting the resident without PPE, despite the facility's policy requiring gloves and gowns for high-contact care activities. Additionally, staff knelt on the floor during wound care without using a barrier, contrary to infection control protocols. Another resident on EBP for an ankle infection did not receive care in accordance with PPE requirements. A registered nurse assessed the resident's foot without gloves or a gown and later stated that PPE was only necessary for toileting, not for wound assessment, indicating a lack of understanding of EBP protocols. Furthermore, staff failed to sanitize blood pressure equipment and a stethoscope after use on a resident, and the nurse acknowledged that the equipment should have been sanitized but did not do so. The facility also did not adhere to CDC and Wisconsin Department of Health Services guidelines regarding staff return-to-work criteria following COVID-19 or gastrointestinal illness. Staff with COVID-19 or GI symptoms returned to work earlier than recommended, and the facility's documentation did not consistently record the date of last symptoms, making it difficult to verify compliance. The infection line lists and time clock records provided did not include necessary information to ensure staff met the required exclusion periods before returning to work.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required, resulting in the inappropriate use of antibiotics for three residents. For one resident with a history of abdominal wall abscess, anemia, endometrial cancer, MRSA infection, and fibromyalgia, the medical record showed that the resident did not meet McGeer's criteria for a urinary tract infection (UTI) based on culture results, yet antibiotic therapy was administered. The physician was not notified that the criteria for infection were not met. Similarly, another resident with a duodenal malignancy, bacterial infection, and a stage 2 sacral pressure ulcer received antibiotics for a skin and soft tissue infection (SSTI) despite only meeting two of the four required new or increasing signs or symptoms per McGeer's criteria. This resident was also omitted from the infection line list, and the physician was not updated regarding the lack of infection criteria. A third resident, with diagnoses including head injury, COPD, and atherosclerotic heart disease, was prescribed antibiotics for a respiratory tract infection (RTI) without documentation of any signs or symptoms meeting McGeer's criteria. The infection documentation only noted a sinus infection without further detail, and the physician was not informed that the resident did not meet the criteria for infection. In all three cases, the facility did not follow its own policy requiring communication of lab results and clinical status to the prescriber to determine the appropriateness of antibiotic therapy.
Failure to Submit PASRR Level II Screens After 30-Day Hospital Exemption Expired
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR) Level I Screen was followed by a Level II Screen when the 30-day hospital exemption expired for two residents. Both residents were identified as suspected of having a serious mental illness on their PASRR Level I Screens and were granted a 30-day hospital exemption. However, after the expiration of the exemption, there was no evidence in the medical records that a PASRR Level II Screen was submitted for either resident. One resident had a diagnosis of anxiety disorder and was prescribed Ativan, with a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment. The other resident had diagnoses of insomnia, depression, and anxiety disorder, was prescribed multiple psychotropic medications, and had a BIMS score indicating moderate cognitive impairment. The Admissions Coordinator confirmed responsibility for completing PASRRs and acknowledged that the required Level II Screens were not submitted after the exemptions expired.
Failure to Ensure Ongoing Dialysis Communication and Fistula Monitoring
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center and did not consistently monitor the fistula site for a resident who required hemodialysis. The resident, who had diagnoses including dementia, anxiety, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic neuropathy, received dialysis three times weekly. Facility policy required daily monitoring of the fistula or graft for pulse, buzzing, or thrill, and regular checks for patency. However, the resident's care plan and Medication Administration Record did not reflect daily monitoring for bruit/thrill, and only eight dialysis communication entries were documented over an eight-month period. Staff interviews confirmed that monitoring for bruit/thrill was not included in the resident's MAR or TAR, and there was confusion among staff regarding what information was sent to and received from the dialysis center. The Director of Nursing and other staff indicated that the facility's policy and physician's orders should be followed, but the required aftercare instructions and consistent communication with the dialysis center were lacking. The dialysis center also reported not receiving the expected documentation from the facility, and there was no communication binder in place for the resident.
Medication Administration Error: Wrong Laxative Given
Penalty
Summary
A deficiency occurred when a registered nurse administered the wrong medication to a resident during the morning medication pass. Specifically, the nurse gave Senna-Plus, which contains both sennosides and docusate sodium, instead of the prescribed Senna 8.6 mg, as documented in the resident's Medication Administration Record (MAR) for constipation. The facility's policy requires medications to be administered according to prescriber orders and for staff to verify the correct medication, dosage, and resident before administration. The error was observed by a surveyor and later confirmed through record review and staff interview, with the Director of Nursing acknowledging that medications should be given as ordered.
Failure to Update Care Plans for Hoyer Sling Use
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for three residents, specifically regarding the practice of leaving Hoyer slings underneath them while seated in Geri chairs and wheelchairs. The facility's policy, dated July 2017, mandates the removal of slings after using a mechanical lift, but this was not adhered to for residents R11, R5, and R3. The surveyor's observations and staff interviews confirmed that the slings were routinely left under residents, contrary to the facility's policy. Resident R11, who has Alzheimer's disease, a history of amputation, and is at high risk for skin breakdown, was observed with a Hoyer sling left under them in a Geri chair. Despite having a care plan for skin integrity issues, the care plan did not include interventions related to the sling. Similarly, Resident R5, who is severely cognitively impaired and at moderate risk for skin breakdown, was observed with a sling left under them in a recliner. R5's care plan also lacked updates regarding the sling. Both residents reported no discomfort from the sling, but the practice was inconsistent with the facility's policy. Resident R3, who is not cognitively impaired and has a history of hemiplegia and diabetes, was observed with a sling left under them after being transferred to a recliner. R3's care plan did include an intervention to leave the sling underneath, but R3 reported discomfort and requested a blanket for additional comfort. Interviews with CNAs and the Director of Nursing revealed that the practice of leaving slings under residents was common, despite the facility's policy requiring their removal. The Nursing Home Administrator mentioned a recent inservice suggesting the practice was acceptable, but no supporting documentation was provided.
Inadequate Use of Assistive Devices Leads to Resident Left Hanging in Lift
Penalty
Summary
The facility failed to ensure the adequate use of assistive devices to prevent injury for a resident, identified as R3, who experienced issues with the lift battery dying mid-transfer. R3, who was not cognitively impaired and required assistance due to conditions such as hemiplegia, hemiparesis, and an acquired absence of the right leg, reported being left hanging in the lift while staff replaced the battery. This situation occurred because the lift battery often died during transfers, and staff had to leave the room to retrieve a new battery. R3 had communicated with maintenance staff about the battery issues, and the facility had ordered new batteries. Interviews with staff revealed that the lift battery dying mid-transfer was a known issue, and staff did not consistently check the battery life before use. The Maintenance Director and Nursing Home Administrator confirmed that new batteries had been ordered and that there were chargers and extra batteries available, although only one battery was observed in the charger during the survey. The Nursing Home Administrator stated that staff should use the manual release to lower residents if a battery dies mid-transfer, but this procedure was not followed, resulting in the resident being left suspended in the lift.
Improper Catheter Bag Placement for Two Residents
Penalty
Summary
The facility failed to provide appropriate care and services for two residents with indwelling catheters, as observed by surveyors. On the specified date, the catheter drainage bags of two residents were found in contact with the floor, contrary to the facility's urinary catheter policy, which aims to prevent urinary-associated complications, including infections. The first resident, who had a history of fractures and hypertension and moderate cognitive impairment, was observed with their catheter bag on the floor due to the bed being in the lowest position. A Certified Nursing Assistant confirmed the improper placement of the catheter bag. The second resident, with a history of hemiplegia, hemiparesis, anemia, and gross hematuria, and severely impaired cognition, was observed with their catheter bag dragging on the floor while attached to their wheelchair. A Licensed Practical Nurse verified the improper placement and adjusted the bag. The Director of Nursing also confirmed that catheter bags should not touch the floor, indicating a lapse in adherence to the facility's infection control procedures.
Inconsistent Adherence to Prescribed Diet for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a prescribed diet was consistently followed for a resident with type 2 diabetes, who was on a consistent carbohydrate hydro-oligomeric (CCHO) diet. During a survey, it was observed that the resident received a full piece of cake instead of the prescribed half piece, as indicated on their meal ticket. The resident accepted the larger portion, stating they were okay with it for that day. The dietary staff, including a cook and a dietary aide, acknowledged the discrepancy and mentioned that they often provided residents with their preferred portion sizes, even if it deviated from the prescribed diet. The dietary manager confirmed that the resident should have received a half piece of cake according to their CCHO diet. However, the facility lacked a policy regarding adherence to prescribed diets, relying instead on staff to follow diet cards. This lack of a formal policy contributed to the inconsistency in following the resident's dietary requirements, as staff prioritized resident preferences over the prescribed diet orders.
Infection Control Deficiency Due to Lack of PPE and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of staff during the care of a resident on Enhanced Barrier Precautions (EBP). On January 9, 2025, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) provided wound care and assisted with the transfer of a resident without wearing the required personal protective equipment (PPE). The resident, who had multiple diagnoses including severe sepsis, open wounds, and a history of stem cell and bone marrow transplants, was on EBP due to the risk of infection. Despite the presence of an EBP sign on the resident's door, the LPN and CNA did not adhere to the facility's policy requiring PPE during high-contact care activities. Additionally, the facility's policy on cleaning and disinfection of resident-care items was not followed. After assisting the resident, the CNA exited the room with a vital signs machine and placed it in the hallway without disinfecting it, contrary to the facility's policy that requires reusable items to be cleaned and disinfected between residents. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that staff should have worn PPE during high-contact care and that durable medical equipment should be sanitized between each resident use.
Failure to Timely Report and Investigate Resident Altercation
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving two residents. The incident involved a resident with intact cognition and another resident with severe cognitive impairment. The altercation occurred when one resident reportedly yelled and rammed their wheelchair into the other resident in the activity room. Although staff were aware of the incident, it was not reported to the administration in a timely manner, leading to a delay in reporting the incident to the State Agency beyond the required 24-hour timeframe. The facility's investigation revealed that staff were aware of the incident on a Friday evening, but the administration was not informed until the following Monday. The investigation could not determine which staff member intervened during the incident. Additionally, there was no proof of education for certain staff members who were on duty during the incident, indicating a lapse in ensuring all staff were trained on reporting requirements. This deficiency highlights a failure in internal reporting processes and staff education regarding abuse allegations.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility did not ensure garbage and refuse were properly disposed of in outside garbage receptacles. During an initial kitchen tour, the surveyor and the Dietary Manager (DM) observed three outside refuse dumpsters with open lids and garbage on the ground. Specifically, a bag of garbage was found behind the middle dumpster, and scattered pieces of paper were observed around all three dumpsters. The DM indicated that the lids were likely open for ease of use but acknowledged they should be shut to prevent rodents. The DM identified the garbage as belonging to Certified Nursing Staff (CNA) but did not take immediate action to remove it.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not allowing six residents to make choices regarding their meals. For instance, Resident 1, who had moderate cognitive impairment and specific dietary needs, was not asked what they wanted to eat and was given an inadequate protein equivalent. The meal provided did not match the dietary instructions on the meal ticket, and the resident expressed that staff did not ask them about their meal preferences. Resident 4, who had a pureed diet and was non-verbal, was not offered the double portions of entrees as indicated in their plan of care. Instead, they received items not listed on the menu or meal ticket, and staff did not verify if the resident's daughter could make dietary choices on their behalf. Similarly, Resident 10, who also had a pureed diet, did not receive the double portions or the correct items listed on their meal ticket. Staff assumed the resident's preferences without asking. Other residents, including Residents 25, 27, and 39, also did not receive meals according to their dietary plans and preferences. Staff made assumptions about their meal choices without consulting them or their activated power of attorney for healthcare. The facility's dietary manager admitted that they did not consider asking residents about their meal preferences, and the regional manager acknowledged that residents' choices were not being honored. The facility planned to implement a new system to address this issue, but at the time of the survey, the deficiency was evident.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide timely written notifications of transfer to three residents (R204, R36, and R19) and did not notify the State Long-Term Care Ombudsman of these transfers. Specifically, R204 was transferred to the hospital due to low blood sugar levels, R36 was transferred twice due to acute kidney injury and low blood pressure with associated symptoms, and R19 was transferred twice due to right-sided weakness and a fall with a head injury. In each case, the medical records did not indicate that the residents received written transfer notices or that the Ombudsman was notified of the transfers. The Assistant Nursing Home Administrator confirmed that written transfer notices were not provided to the residents, and the facility's records showed that the Ombudsman was not notified of the transfers. The Nursing Home Administrator indicated that nurses are expected to use the facility's transfer form when a resident is transferred to the hospital, but this procedure was not followed. The facility's documentation policy, revised in December 2016, requires that details of the transfer or discharge be documented in the medical record and communicated to the receiving healthcare provider, including providing appropriate notices to the resident and/or legal representative.
Failure to Provide Bed Hold Policy Information
Penalty
Summary
The facility did not ensure that three residents received written information regarding the duration of the facility's bed hold policy, the reserve bed payment policy, and the right to return to the facility when they were transferred to the hospital. Resident 204 was transferred to the hospital due to a low blood glucose reading and did not receive a copy of the bed hold policy. This was confirmed by the Assistant Nursing Home Administrator. Similarly, Resident 36 was transferred to the hospital twice, once for acute kidney injury and once for low blood pressure, headache, and dizziness, but did not receive the bed hold policy on either occasion. The Assistant Nursing Home Administrator confirmed that the bed hold policy was not provided for these transfers, despite a nursing note being completed. Resident 19 was transferred to the hospital twice, once due to right-sided weakness and once due to a fall with a head injury, and did not receive a copy of the bed hold policy on either occasion. The Assistant Nursing Home Administrator confirmed that the bed hold policy was not provided for these transfers. The Nursing Home Administrator indicated that it is expected for nurses to provide a copy of the facility's bed hold policy and transfer form when a resident is transferred to the hospital. However, this expectation was not met in these cases, leading to the deficiency.
Failure to Ensure Resident Safety and Proper Fall Management
Penalty
Summary
The facility did not ensure each resident received adequate supervision and assistive devices, did not complete fall assessments, and did not implement interventions to prevent falls for two residents. On one occasion, staff used a lift with defective brakes and a defective sling to transfer a resident. Despite repeated warnings from a CNA about the broken sling, it continued to be used. Additionally, the lift with broken brakes was used because the other lift was in use, and management was not aware of the issue until the surveyor's observation. Another resident experienced a fall with a head injury, and the facility failed to appropriately assess the resident following the fall. The resident's care plan was not updated with new interventions to prevent future falls. Despite the IDT's review, the care plan remained unchanged, and the interventions were not accessible to CNAs. Neurochecks were not completed as required, and the documentation was inconsistent with the facility's policies. The facility's policies on safety, supervision, and fall risk management were not followed. The use of defective equipment and the lack of proper assessment and documentation contributed to the deficiencies. The facility's failure to update care plans and ensure staff access to new interventions further exacerbated the issue, leading to inadequate care and supervision for the residents involved.
Failure to Provide Necessary Respiratory Care
Penalty
Summary
The facility did not ensure that a resident received the necessary care and services for respiratory therapy. The resident was provided with CPAP therapy without a physician's order, and the need for and use of CPAP therapy was not included in the care plan for assessment, evaluation, or monitoring. The facility's CPAP Therapy policy requires a physician's order and documentation of various aspects of the therapy, which were not followed in this case. Additionally, the facility's Respiratory Therapy-Prevention of Infection policy outlines specific procedures for preventing infection, which were also not adhered to, as evidenced by the lack of labeling on the CPAP machine's tubing to indicate when it was last changed. The resident, who had diagnoses including obstructive sleep apnea, dementia, weakness, and anxiety, was observed with a CPAP machine on the bedside table. The resident indicated that not all staff were educated on the CPAP mask/machine, leading to inconsistent use. The Director of Nursing confirmed that the resident did not have a physician's order for CPAP therapy and that the care plan did not address the use of CPAP therapy or the cleaning schedule for the equipment. The tubing on the CPAP machine was also not labeled with a date/time, which is necessary for infection prevention.
Failure to Monitor High-Risk Medication
Penalty
Summary
The facility did not ensure proper monitoring of a high-risk medication for one resident diagnosed with diabetes mellitus. The resident had physician orders for both short-acting and long-acting insulin to manage high blood sugar levels. However, the resident's plan of care lacked interventions to monitor for signs and symptoms of hypoglycemia and hyperglycemia. This deficiency was identified during a review of the resident's medical record and confirmed through an interview with the Director of Nursing (DON). The resident's medical record included specific orders for Humalog and Lantus insulin, with detailed instructions on dosage and administration. Despite these orders, the resident's baseline care plan did not address the need to monitor for potential complications related to blood sugar levels. The DON acknowledged that the comprehensive care plan was incomplete and that the baseline care plan did not include necessary monitoring interventions for hypoglycemia and hyperglycemia.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with 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.
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.
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 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.
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.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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