Pine Valley Community Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Richland Center, Wisconsin.
- Location
- 25951 Circle View Lane, Richland Center, Wisconsin 53581
- CMS Provider Number
- 525365
- Inspections on file
- 21
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Pine Valley Community Village during CMS and state inspections, most recent first.
A resident with chronic pain and severe cognitive impairment was prescribed hydrocodone-acetaminophen 7.5-325 mg, first as PRN for breakthrough pain and later scheduled every eight hours. Facility policy required dual-signature controlled administration sheets upon receipt from pharmacy and shift-to-shift narcotic counts documented in narcotic binders. The MAR showed scheduled hydrocodone-acetaminophen was administered three times daily during a month, except for a few missed doses when the resident was out of the facility. However, when a surveyor requested the controlled drug receipt/record/disposition forms for that month, the DON could only provide forms for earlier dispensing dates and acknowledged that the forms for the month in question were missing, making it impossible to reconcile the controlled medication as required.
Surveyors found that five CNAs did not complete the required 12 hours of annual continuing education, as confirmed by both documentation review and administrator interview. This lapse in in-service education could impact all 70 residents in the facility.
Five CNAs did not receive required education in effective communication, as confirmed by the NHA when surveyors requested documentation. The lack of training was identified through interviews and record review, potentially impacting all residents.
The facility did not provide required QAPI program education to five CNAs, as confirmed by the NHA and a lack of documentation when requested by a surveyor.
Four CNAs did not receive required infection control education, and the NHA could not provide evidence of their training when requested by surveyors. This lapse in mandatory staff education has the potential to impact all 70 residents.
Five CNAs did not receive required compliance and ethics training, as confirmed by the NHA when surveyors requested documentation. The lack of training was identified through interviews and record review, potentially affecting all residents in the facility.
Surveyors found that opened bags of chicken patties in the freezer were not sealed or dated as required by facility policy, and high temperature dishwashers in several kitchenettes repeatedly operated below the minimum recommended wash temperatures without proper documentation or notification to management.
Two residents with chronic respiratory conditions and intact cognitive status were found with medications at bedside or on meal trays without completed self-administration assessments or physician orders. Staff interviews confirmed that neither resident was authorized to self-administer the medications observed, and facility policy requiring assessment, physician order, and secure storage was not followed.
A registered nurse did not receive a complete background check as required by facility policy, which mandates such checks upon hire and every four years. The omission was confirmed by Human Resources, who could not explain why the check was missed.
Surveyors found that two residents did not receive their scheduled morning medications within the required time window, resulting in a medication error rate of over 40%. Medications were administered outside the one-hour window specified by facility policy, and the DON confirmed these were medication errors.
A bottle of MiraLAX prescribed to a resident was found unattended on top of a medication cart in a common area near the dining room, with no nurse present and residents and visitors nearby. Facility policy requires medications to be stored in locked carts or rooms, or kept within a nurse's line of sight, which was not followed in this instance.
An LPN did not perform hand hygiene between glove changes during a wound care procedure for a resident with a neuropathic toe wound. The LPN touched items in the environment and changed gloves without sanitizing hands, contrary to facility policy. Both the LPN and DON confirmed awareness of proper hand hygiene requirements.
Two residents experienced acute changes in condition that were not promptly recognized or appropriately managed by staff. One resident with multiple chronic illnesses was not assessed or monitored for over 21 hours despite worsening symptoms and was only sent to the ER after a nurse practitioner intervened, later being diagnosed with sepsis and acute respiratory failure. Another resident with a history of atrial fibrillation was not monitored as ordered after reporting irregular heart rates and chest pressure, and was sent to the ER via taxi instead of ambulance after experiencing tachycardia and bradycardia. These failures to assess, monitor, and use appropriate transport led to Immediate Jeopardy findings.
A resident with moderate cognitive impairment reported missing money, prompting an investigation by the Social Services Director that included interviews with the resident and staff, a search of the resident's room, and notification of law enforcement and family. However, the facility did not interview other residents to determine if similar concerns existed, as required by policy, and did not provide staff education following the incident. The resident had not received reimbursement or follow-up communication regarding the missing funds.
A CNA worked for 11 days with an expired Wisconsin Nurse Aide Registry certification. The facility's administrator was unaware of the lapse until it was identified during a survey, and documentation confirmed the CNA had continued working without current certification as required.
The facility did not complete required annual performance evaluations for three CNAs, as mandated by facility policy. The administrator confirmed that yearly evaluations are expected and that all CNAs should have current evaluations.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, affecting all 62 residents. Nutritional supplements were not dated or were expired, food boxes were on the floor, staff did not wear hairnets, and dishwasher temperatures were not monitored.
The facility failed to report reasonable suspicions of abuse to law enforcement for two residents. One resident with severe cognitive impairment reported being hurt by a staff member, and another resident reported rough handling by a CNA. Despite internal investigations and state agency reports, local law enforcement was not notified.
Failure to Maintain Controlled Drug Accountability Records for Hydrocodone-Acetaminophen
Penalty
Summary
The deficiency involves the facility’s failure to maintain required records for a controlled substance prescribed to a resident. Facility policy required that upon receipt of controlled medications from the pharmacy, both the pharmacy and a licensed nurse sign controlled administration sheets, and that all controlled medications be accounted for each shift by oncoming and outgoing nurses using controlled administration sheets stored in a narcotic binder on each medication cart. The facility also had a HIPAA documentation policy requiring secure maintenance and availability of required documentation for audits and investigations. A resident with rheumatoid arthritis, chronic pain, and severe cognitive impairment (BIMS score of 1) had physician orders for hydrocodone-acetaminophen 7.5-325 mg, initially as a PRN dose for breakthrough pain and later scheduled every eight hours for pain. The MAR for December showed the PRN dose was not given, while the scheduled dose was administered three times daily except for five doses when the resident was out of the facility. When the surveyor requested the resident’s controlled drug receipt/record/disposition forms for hydrocodone-acetaminophen, the DON produced forms dated for multiple prior dispensing dates, each showing pharmacy delivery of 30 tablets, but was unable to provide the controlled drug forms for the month of December. During interviews, the DON confirmed that she did not have the December controlled drug forms and stated she was unable to reconcile the resident’s hydrocodone-acetaminophen for December without those records. As a result, the facility did not have a complete system of records of receipt and disposition of this controlled drug and could not account for all doses administered or dispensed during that month, contrary to its own policies and regulatory requirements for controlled drug accountability.
Failure to Provide Required Annual CNA In-Service Education
Penalty
Summary
The facility failed to provide regular in-service education for all five Certified Nursing Assistants (CNAs) reviewed for education, as required by Wisconsin regulations mandating 12 hours of continuing education annually for CNAs. Documentation requested by the surveyor showed that none of the five CNAs—each with varying hire dates—had completed the required 12 hours of continuing education within the past 12 months. During an interview, the Nursing Home Administrator confirmed that these CNAs should have completed their annual education hours but had not done so. This deficiency was identified through both record review and staff interview, and it has the potential to affect the entire resident census of 70.
Failure to Provide Mandatory Effective Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to ensure that five direct care staff members received mandatory education in effective communication. During a survey, the surveyor requested documentation confirming that these staff members had completed the required training. The Nursing Home Administrator (NHA) was unable to provide evidence that the education had been provided to the identified Certified Nursing Assistants (CNAs). The NHA confirmed in an interview that these staff members should have received the training but did not. This deficiency was identified through interviews and record reviews and has the potential to affect the facility's entire resident census.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on the elements and goals of the Quality Assurance and Performance Improvement (QAPI) program. During an interview and record review, it was found that five Certified Nursing Assistants (CNAs) did not receive the required QAPI education. When the surveyor requested evidence of QAPI education for these staff members, the Nursing Home Administrator (NHA) was unable to provide documentation confirming that the training had been completed. The NHA confirmed in an interview that these CNAs should have received the QAPI education but did not.
Failure to Provide Mandatory Infection Control Training to Staff
Penalty
Summary
The facility failed to ensure that four out of five staff members reviewed for education received the required mandatory training on infection control standards, policies, and the overall infection prevention and control program. During the survey, the surveyor requested evidence of infection control education for four Certified Nursing Assistants (CNAs), but the Nursing Home Administrator (NHA) was unable to provide documentation that these staff members had received the necessary training. The NHA confirmed in an interview that these CNAs should have received infection control education but did not. This deficiency has the potential to affect the entire resident census of 70.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) received required training on compliance and ethics. During a survey, the surveyor requested evidence of compliance and ethics training for five specific CNAs. The Nursing Home Administrator (NHA) was unable to provide documentation that these staff members had received the necessary training. The NHA confirmed in an interview that the identified CNAs should have received the training but did not. This deficiency was identified through both interview and record review, and it has the potential to affect the facility's total census of 70 residents.
Deficiencies in Food Storage and Dishwasher Temperature Monitoring
Penalty
Summary
Surveyors identified deficiencies in the facility's food storage and dishwashing practices. During an inspection of the main kitchen, two opened bags of chicken patties were found in the walk-in freezer that were not sealed and lacked both an opened date and a use by date, contrary to the facility's own policy requiring opened food items to be sealed and labeled with the date. The Dietary Manager confirmed that staff were expected to seal and date opened food items, but this was not done in this instance. Additionally, the facility's high temperature dishwashers in multiple kitchenettes were found to be operating below the minimum recommended wash temperatures on several days, as documented in temperature logs. The logs showed repeated instances where dishwashers did not reach the required 150 degrees F for proper sanitization. The Dietary Manager stated that staff are supposed to rerun dishes and notify her if temperatures are not met, but there was no documentation of these actions, and she was not informed of the temperature issues as expected. The facility also lacked a policy or procedure for monitoring dishwasher temperatures.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were clinically assessed and authorized to self-administer medications before allowing them access to their medications at bedside. In one instance, a resident with chronic respiratory failure, COPD, and a BIMS score indicating cognitive intactness was observed with a Combivent Respimat inhaler and a mouth spray on the bedside table. The resident stated the items had been there for at least a day but could not recall who placed them there. Review of the resident's records showed a self-administration assessment and plan of care only for nebulizer use after nurse setup, with no assessment or plan for the inhaler or mouth spray. Interviews with nursing staff confirmed that the resident was not authorized to self-administer these medications and that such medications should not be left at bedside without proper assessment and physician order. Another resident, also with chronic respiratory failure, COPD, and a BIMS score indicating cognitive intactness, was observed with a cup of medications left on the meal tray at bedside. The resident reported receiving the medication cup that morning. When questioned, the medical assistant confirmed that the resident liked to take medications independently but could not find documentation of an assessment or physician order authorizing self-administration. The nurse supervisor later clarified that the resident was only authorized to self-administer topical creams, not oral medications, and that oral medications should not be left on the meal tray. The facility's policy requires that residents wishing to self-administer medications must undergo a self-administration assessment, and if deemed safe, a physician order must be obtained. Additionally, medications must be kept in a secure location between administrations. In both cases, the facility did not follow its own policy, as neither resident had the required assessment or physician order for the medications found at bedside, and medications were not secured as required.
Failure to Complete Required Employee Background Check
Penalty
Summary
The facility failed to implement its policy and procedures regarding the screening of employees for a prior history of abuse, neglect, exploitation, or misappropriation of resident property. Specifically, one registered nurse did not have a complete background check performed every four years as required by facility policy. The policy, titled 'Abuse Investigation and Reporting,' mandates that all employees undergo a full background check, including a Background Information Disclosure (BID), Department of Justice (DOJ) check, and review of government findings upon hire and every four years thereafter. Record review showed that the registered nurse, hired in 2019, did not have the required background check completed in 2023. During an interview, the Human Resources representative confirmed that the background check for this employee was missed and could not provide a reason for the oversight.
Medication Error Rate Exceeds Regulatory Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5%, as required by regulation and facility policy. During a medication pass observation, surveyors identified 11 errors out of 27 opportunities, resulting in a medication error rate of 40.74%. The errors involved two residents who did not receive their morning medications at the correct, ordered time. According to the facility's policy, medications scheduled for 7:30 AM must be administered within one hour before or after the scheduled time, specifically between 6:30 AM and 8:30 AM. One resident, with diagnoses including chronic atrial fibrillation, congestive heart failure, and type 2 diabetes mellitus, was observed receiving multiple morning medications at 8:57 AM, which was outside the permitted administration window. The medications included digoxin, furosemide, Jardiance, acetaminophen, and omeprazole, all of which were ordered for administration at 7:30 AM. The resident was cognitively intact, as indicated by a BIMS score of 15, and the medication orders were clearly documented in the EMAR. A second resident, with severe cognitive impairment and diagnoses such as atrial fibrillation, hypertension, dementia with agitation, and pruritus, was also observed receiving all scheduled 7:30 AM medications at 8:55 AM, again outside the allowed timeframe. The medications administered included digoxin, amlodipine, furosemide, losartan, quetiapine, and prednisolone, all ordered for 7:30 AM administration. The Director of Nursing confirmed that these administration times constituted medication errors according to facility policy.
Unattended Medication Left on Cart in Common Area
Penalty
Summary
A deficiency occurred when a bottle of polyethylene glycol powder for oral solution (MiraLAX), prescribed to a resident, was observed sitting unattended on top of a medication cart located in a common area near the dining room, where two residents and two visitors were present. The medication cart was not within the line of sight of a nurse at the time of the observation. According to the facility's Medication Administration policy, medications are to be stored in locked carts or rooms, and carts not in medication rooms must be locked when not in use or kept within the nurse's line of sight. Upon return, the registered nurse confirmed the medication was MiraLAX and acknowledged that medications should probably not be left unattended. The Director of Nursing also confirmed that medications are not to be left on top of the cart unattended.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene protocols during a wound care procedure for a resident. The facility's policy requires staff to wash hands and change gloves at specific steps during wound care, including after removing old dressings and before applying new ones. During observation, the LPN washed her hands initially, but after removing gloves used to take off the resident's shoe and sock, she donned new gloves without sanitizing her hands. She then proceeded to remove the old dressing, cleanse the wound, and apply a new dressing without performing hand hygiene between glove changes as required by policy. The resident involved had been admitted with a diagnosis that included a hammer toe and developed a non-pressure, neuropathic wound on the dorsal aspect of the left second toe during her stay. Interviews with the LPN and the Director of Nursing (DON) confirmed that both were aware of the need for hand hygiene between glove changes and after touching items in the environment. The LPN acknowledged she should have sanitized her hands after touching the paper and the resident's shoes, and before continuing with the wound care procedure.
Failure to Recognize and Respond to Acute Changes in Condition
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards of practice for two residents, resulting in significant deficiencies. In the first case, a resident with multiple comorbidities including diabetes, dementia, chronic kidney disease, and PTSD experienced a change in condition characterized by severe back pain, low oxygen saturation, and shortness of breath. Despite physician and healthcare power of attorney involvement, there was a lack of documented assessment and monitoring for over 21 hours. The resident's condition worsened, and he was not sent to the emergency room until the nurse practitioner intervened. Upon hospital admission, the resident was diagnosed with sepsis, pneumonia, and acute respiratory failure with hypoxia, and subsequently passed away two days later. In the second case, another resident with a history of atrial fibrillation, heart failure, and other cardiac conditions reported irregular heart rates and chest pressure. The on-call physician provided explicit orders to send the resident to the emergency room if the apical pulse exceeded 115. However, staff did not assess or monitor the resident's pulse for the next ten hours, during which the resident experienced episodes of tachycardia and bradycardia, as well as chest tightness. The resident was eventually sent to the hospital, but was transported via taxi rather than a medical transport service, despite presenting with acute cardiac symptoms. The facility's failures included not recognizing acute changes in condition, not closely monitoring or assessing residents as ordered, and not using appropriate medical transport during emergencies. These actions and inactions resulted in delayed treatment and intervention for both residents, and the surveyor determined that these failures constituted Immediate Jeopardy. The facility's own policies and professional standards were not followed, as evidenced by the lack of timely assessments, documentation, and appropriate escalation of care.
Removal Plan
- Staff education on change in condition, including what is a change in condition, how to recognize it, appropriate response, physician notification, and assessments required.
- Staff are required to review education prior to the start of their shift.
- Staff are educated to assess the resident for change in condition, gather vitals, symptoms, and changes above baseline condition at a minimum of twice a shift or transfer for further evaluation.
- Physician should be notified upon change in condition, vitals, symptoms, interventions, reactions, pain, infections, neurological changes, or falls as soon as possible following change in condition.
- Mandatory all staff meeting regarding change in condition and follow up from education provided to ensure understanding of requirements and to obtain feedback.
- Education will be provided for new hires during orientation in the form of the same education provided to staff; agency staff will be given the same information.
- Management staff will conduct scenario-based competencies with staff.
Failure to Conduct Thorough Investigation of Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation in response to an allegation of misappropriation of a resident's property. A resident with moderate cognitive impairment reported missing $42 from her purse, and the Social Services Director initiated an investigation by interviewing the resident, searching her room and purse with her permission, contacting law enforcement, and notifying the resident's daughter. The facility also interviewed 12 staff members who worked around the time of the incident. However, the investigation did not include interviews with other residents to determine if there were similar concerns or additional allegations of missing property. The facility's policy requires a thorough investigation of alleged violations, including interviewing other residents to identify any related issues. Documentation and interviews confirmed that no other residents were interviewed, and no staff education was provided following the incident. The resident expressed dissatisfaction with the lack of follow-up and had not yet been reimbursed for the missing money at the time of the survey. The deficiency was identified based on the facility's failure to follow its own policy and regulatory requirements for investigating allegations of misappropriation.
CNA Worked with Expired Certification
Penalty
Summary
A Certified Nursing Assistant (CNA) continued to work in the facility for 11 days after her Wisconsin Nurse Aide Registry certification had expired. The surveyor reviewed the registry information and found that the CNA's certification was not current, despite the requirement that nurse aides must be listed on the Wisconsin Nurse Aide Registry to be employed in federally eligible health care settings in Wisconsin. The Nursing Home Administrator was unaware of the expired certification until it was brought to her attention during the survey. Documentation provided by the facility confirmed that the CNA had worked during the period her certification was expired.
Failure to Complete Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to complete a performance review of every Certified Nursing Assistant (CNA) at least once every 12 months for 3 out of 5 CNAs reviewed. Specifically, CNA K, CNA L, and CNA M did not have annual performance evaluations completed, despite their respective hire dates indicating that such evaluations were due. The facility's policy requires annual performance reviews and regular in-service education based on these reviews. During an interview, the Nursing Home Administrator confirmed that CNA evaluations are to be conducted yearly and that all CNAs should have up-to-date evaluations.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all 62 residents. Observations revealed that nutritional supplements and food items were not dated or were expired. Specifically, various units had nutritional juices and shakes without thaw dates, and some items were past their use-by dates. The Dietary Manager admitted that there was no policy or procedure regarding the handling of nutritional shakes and drinks. Additionally, boxes of food were found sitting directly on the floor in multiple areas of the kitchen, which the Dietary Manager acknowledged should not happen. Further observations showed that staff members were not adhering to hygiene protocols, as one RN was seen walking through the kitchen without a hairnet, despite a posted sign requiring it. The temperature of the dishwashers in the kitchenettes was also not being monitored properly. In the 400 unit kitchenette, there was no thermometer to document the internal temperature of the dishwasher, and the Dietary Manager was unaware of when it had disappeared or how long the temperature had not been monitored. These deficiencies indicate a lack of adherence to food safety and hygiene standards in the facility's food service operations.
Failure to Report Abuse to Law Enforcement
Penalty
Summary
The facility failed to report reasonable suspicions of abuse to law enforcement for two residents. Resident 58, who has severe cognitive impairment and multiple medical conditions, reported to a Registered Nurse that a staff member had hurt him. Despite the facility initiating an internal investigation and reporting the incident to the Division of Quality Assurance, law enforcement was not contacted. Interviews with the Social Worker and the Director of Nursing revealed that the police were not notified, although both acknowledged that they should have been informed of the abuse allegation. Similarly, Resident 49 reported that a Certified Nursing Assistant was rough during a transfer, causing fear and physical pain. The facility conducted an internal investigation and reported the incident to the state agency but did not notify local law enforcement. Interviews with the Social Worker who handled the report indicated uncertainty about whether the incident constituted abuse, despite the resident's description of being pushed and scared. The failure to report these incidents to law enforcement constitutes a deficiency in the facility's abuse reporting procedures.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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