Pine View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Black River Falls, Wisconsin.
- Location
- 400 County Rd R, Black River Falls, Wisconsin 54615
- CMS Provider Number
- 525409
- Inspections on file
- 30
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Pine View Care Center during CMS and state inspections, most recent first.
A resident with dementia and severely impaired cognition, care planned for sit-to-stand lift use for all transfers and dependent for transfers and toileting, was observed being transferred from the bathroom to a wheelchair on a sit-to-stand lift by a single CNA, contrary to facility policy and staff expectations that all mechanical lift transfers require two staff. The CNA acknowledged receiving training, knowing that two staff were required for lift use, and understanding that this resident needed two-person assistance, but proceeded alone because the nurse was busy. Other CNAs, an RN, and facility leadership all confirmed that two-person assistance is required for all lift equipment transfers and that the resident’s care plan called for use of the sit-to-stand lift.
A resident with type 2 DM on a prescribed sliding scale insulin lispro regimen did not receive two ordered insulin doses when blood glucose readings required administration. Facility policy required blood sugar monitoring and sliding scale insulin per MD orders. On two separate occasions, blood glucose values fell within the range requiring 2 units of insulin, but no insulin was given. One missed dose occurred when a nurse became occupied with another resident’s fall and forgot to administer insulin, and the other occurred when a med tech failed to report the blood sugar result to the nurse, resulting in the nurse not giving the ordered dose.
A resident with significant care needs was subjected to verbal abuse and rough handling by a CNA, as witnessed and reported by staff. The resident expressed feeling mistreated and fearful, and the incident was reported to facility leadership. However, the CNA was not removed from resident care during the investigation, which was limited in scope and not reported to the State Agency as required.
The facility did not follow its abuse prevention and reporting policies for two residents. In one case, a CNA was reported for yelling and rough handling, but was not removed from care and the incident was not reported to the State Agency. In another case, staff used a stern tone and inappropriate comments during a transfer, causing anxiety for a resident, but the incident was not fully investigated or reported. Both cases lacked thorough investigation and failed to meet required reporting procedures.
The facility did not report two separate allegations of abuse involving two residents to the State Survey Agency or law enforcement as required. In one case, a staff member reported that a CNA was rough and yelled at a resident, and in another, a family member reported staff using an inappropriate and abrupt approach during a transfer, causing distress to a resident with atrial fibrillation and hypertension. Both incidents were acknowledged by facility leadership as allegations of abuse but were not reported according to policy.
Two residents' allegations of abuse were not thoroughly investigated, with incomplete interviews and no evidence of protective measures or timely reporting to the state. In both cases, staff and family reported rough or inappropriate treatment by CNAs, but the facility failed to follow its abuse policy and regulatory requirements.
A resident with a right below the knee amputation, who required a full body mechanical lift for transfers per their care plan, was transferred using a sit-to-stand mechanical lift by a CNA. This action was not in accordance with the resident's care plan or facility policy, which specifies the use of a full body lift for residents unable to bear weight.
A resident's advance directive was not properly documented or accessible in the facility's records, despite policy requirements to discuss and record CPR/DNR orders upon admission. Staff interviews confirmed the absence of necessary documentation, and hospital transfer documents indicating DNR status were not placed in an accessible location.
A facility failed to maintain a medication error rate of 5% or less, with a surveyor observing 2 errors out of 27 opportunities, resulting in a 7.41% error rate. A resident received insulin injections from pens that were not primed as per manufacturer's instructions, due to the RN's lack of awareness about the priming requirement. The DON was also unsure about the facility's policy on insulin pen use.
The facility failed to maintain food safety standards by serving potentially hazardous foods at improper temperatures and transporting uncovered food trays through hallways. Pureed lasagna was served at 128 degrees Fahrenheit, below the required 135 degrees, affecting two residents on a pureed diet. Additionally, an LPN delivered uncovered food items to residents' rooms, contrary to facility expectations.
A resident dependent on staff for eating was fed in an undignified manner by a CNA who repeatedly wiped food from the resident's face with a spoon and re-fed it to them. The CNA was unaware that this practice was inappropriate, and the DON confirmed it violated dignity and infection control standards.
A resident with severe cognitive impairment and significant health issues did not receive adequate assistance with meals, leading to poor nutrition. Despite care plan instructions and therapy recommendations, staff provided minimal help and did not offer alternative foods or fluids. Observations and staff interviews revealed inconsistent and inadequate meal assistance.
The facility failed to conduct a comprehensive trauma-informed assessment and develop a care plan for a resident with a significant history of trauma and related diagnoses, despite the facility's policy requiring such assessments.
A resident received 10 units of Insulin Aspart (Humalog) 58 minutes before their meal, contrary to guidelines that recommend administering rapid-acting insulin within 0-15 minutes before a meal or immediately after. The RN acknowledged the mistake, and the DON confirmed the correct protocol.
Failure to Use Required Two-Person Assist for Mechanical Lift Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible by not following its own policy requiring two staff members for all mechanical lift transfers. The facility’s Body Mechanics - Transfer Training policy, reviewed in 11/2024, specifies that two CNAs, licensed nurses, or therapists are required for mechanical sit-to-stand and full-body lift use. The resident involved, R3, was admitted with dementia and had a BIMS score of 00, indicating cognition not intact. R3’s most recent MDS documented a need for substantial/maximal assistance with bed mobility and dependent assistance with toileting hygiene, sit-to-stand, chair/bed transfers, and toilet transfers. R3’s care plan required use of a sit-to-stand lift for all transfers and documented toileting assistance of one. During observation, the surveyor saw that R3 was transferred from the bathroom to a wheelchair using a sit-to-stand lift by one CNA (CNA D) without a second staff member present. CNA D confirmed she had been trained on safe transfer techniques and knew that two staff were required for lift equipment transfers, and she stated she was aware R3 needed two staff for use of the lift machine but proceeded alone because the nurse was busy and R3 needed to be transferred. Other staff interviewed, including another CNA and an RN, stated that the expectation was that two staff are required for all lift transfers, and review of R3’s care plan by staff confirmed that a sit-to-stand lift was required for transfers, which they understood to mean two staff assistance. Facility leadership also acknowledged that the expectation is for two staff to assist with resident transfers using lift equipment and that this was a concern given repeated staff education on resident safety with lift transfers.
Missed Sliding Scale Insulin Doses for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to insulin administration. Facility policy on diabetic blood sugar monitoring, last reviewed in 11/2022, requires that blood sugars be measured and recorded per physician orders and that sliding scale insulin be given as ordered. The resident, admitted with type 2 diabetes mellitus without complications, had a physician order for insulin lispro on a sliding scale four times daily, with specific unit doses tied to blood glucose ranges and an instruction to call the physician for readings over 400. Review of the medication administration record showed that on 02/28/26 the resident’s morning blood sugar was 154, which required administration of 2 units of insulin lispro per the sliding scale order, but no insulin was given. Further review showed that on 03/15/26 the resident’s lunchtime blood sugar was 192, again requiring 2 units of insulin lispro per the physician’s sliding scale order, and no insulin was administered. During an interview on 03/23/26, the Clinical Services Consultant explained that every other weekend a med tech obtains diabetic blood sugars and informs the nurse of the results so the nurse can administer insulin. On 02/28/26, another resident experienced a fall, and the nurse became busy and forgot to administer the ordered insulin dose. On 03/15/26, the med tech did not inform the nurse of the resident’s blood sugar result, and the nurse did not administer the lunchtime insulin dose. The Clinical Services Consultant confirmed that these missed doses constituted medication errors and that insulin should have been administered on both occasions.
Failure to Protect Resident from Verbal Abuse and Rough Handling by CNA
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) engaged in verbal abuse and rough handling of a resident who required extensive assistance with activities of daily living due to diagnoses including renal cancer, urine retention, and hydronephrosis. The resident reported feeling like an animal during care and expressed fear of staff, stating that staff were rough and used inappropriate language. The resident also indicated that they had reported these concerns to facility leadership. Multiple staff interviews confirmed that the CNA was observed swearing at the resident and handling them roughly during care. A housekeeper witnessed the CNA cursing at the resident and placing their legs harshly on wheelchair pedals, and reported hearing the CNA yelling from down the hall. The housekeeper reported the incident to a Registered Nurse (RN), who in turn reported it to the Nursing Home Administrator (NHA). However, neither the housekeeper nor the RN intervened to remove the resident from the situation or to have the CNA leave the room at the time of the incident. Despite the allegations and reports, the CNA was not removed from resident care during the investigation. The facility's investigation was limited, consisting of only three handwritten staff interviews without times or signatures, and did not include interviews with other staff or residents. The incident was not reported to the State Agency as required, and the NHA acknowledged that the event constituted an allegation of abuse but did not take further investigative or protective actions.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures prohibiting abuse, neglect, and mistreatment for two residents. In the first instance, a housekeeper reported to a registered nurse that a certified nursing assistant (CNA) was yelling, swearing, and handling a resident roughly during care. The registered nurse reported the incident to the nursing home administrator, but the CNA was not removed from resident care during the investigation. The facility's investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, and no additional interviews with other staff or residents were conducted. The incident was not reported to the State Agency as required by facility policy. In the second case, a family member raised concerns about staff approach and communication during a transfer of another resident who had recently transitioned to using an EZ stand. The family member reported that staff were abrupt, used a stern voice, and made inappropriate comments, causing the resident to become anxious and confused. The staff told the resident she could remain in the chair and go to the bathroom there, then left the room without assisting further. The family member reported the incident to the social worker, who documented it as a grievance. The social worker and administrator both acknowledged the incident could be considered abuse, but the incident was not reported to the State Agency, and a full investigation was not completed. Both incidents demonstrate that the facility did not follow its own abuse policy, which requires immediate safeguarding of residents, thorough investigation of all allegations, and timely reporting to the State Agency. In both cases, the facility failed to remove the alleged perpetrator from resident care during the investigation, did not conduct comprehensive interviews, and did not report the allegations as required by policy and regulation.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the facility administrator and to the State Survey Agency, as well as to law enforcement, as required by both facility policy and state law. In two separate cases, allegations of abuse were not reported to the appropriate authorities. In the first case, a staff member reported that a CNA was yelling at and being rough with a resident. The Nursing Home Administrator (NHA) acknowledged receiving the report and initiating an investigation but did not report the incident to the State Agency or law enforcement. Documentation of the investigation was incomplete, consisting only of three unsigned, undated handwritten interviews, with no additional interviews from other staff or residents. In the second case, a family member raised concerns about the manner in which staff transferred a resident using an EZ stand, describing the staff's approach as abrupt and inappropriate. The family member reported that staff made negative comments about the resident, such as calling her non-compliant and unmotivated, and told her she could remain in her chair or fall on the floor. The resident became emotional, tearful, and confused as a result. The incident was reported to the facility's social worker and documented as a grievance. Both the social worker and the NHA acknowledged that the incident constituted an allegation of abuse and that it should have been reported to the State Agency within two hours, but no such report was made to the State Agency or law enforcement. The residents involved included one with diagnoses of atrial fibrillation and hypertension, who was newly admitted and unfamiliar with the EZ stand transfer device. The failure to report these allegations of abuse as required by policy and regulation represents a deficiency in the facility's abuse reporting procedures. The events were substantiated through interviews with staff, the NHA, the social worker, and the family member, as well as review of grievance documentation.
Failure to Thoroughly Investigate and Protect Residents Following Abuse Allegations
Penalty
Summary
The facility failed to ensure that allegations of abuse involving two residents were thoroughly investigated, as required by its own policies and federal regulations. In the first instance, a staff member reported that a certified nursing assistant (CNA) was rough and yelled at a resident during a transfer, with the resident's pant leg becoming stuck in the wheelchair. The facility's investigation consisted only of three handwritten interviews lacking interview times and signatures, and did not include interviews with other staff or residents. The nursing home administrator confirmed that no additional interviews were conducted and that the CNA was not suspended or removed from patient care during the investigation. There was also no evidence that protective measures were put in place to prevent further potential abuse during the investigation process. In the second instance, a family member reported concerns about the approach staff used while transferring another resident with an EZ stand, describing the staff as abrupt and communicating inappropriately. The family member stated that staff made negative comments about the resident's motivation and compliance, and told the resident she could remain in the chair. The facility provided interviews with the resident, the family member, and two CNAs (only one of whom was present during the incident). Although the facility provided documentation of staff education on resident approach and abuse policy, the nursing home administrator acknowledged that a full investigation was not completed and that the incident was not reported to the state as required. Both cases demonstrate that the facility did not follow its own abuse policy, which mandates immediate safeguarding of residents, thorough investigation of all alleged violations, and reporting to the state agency within specified timeframes. The lack of comprehensive investigations and failure to implement protective measures for the residents involved resulted in noncompliance with regulatory requirements for responding to allegations of abuse.
Improper Transfer Method Used for Resident with Amputation
Penalty
Summary
A deficiency occurred when a resident with a right below the knee amputation, who was care planned for transfer with a full body mechanical lift and assistance of two staff, was instead transferred using a sit-to-stand mechanical lift. The facility's policy specifies that residents who cannot sit, stand, or bear weight should not be lifted manually and require a mechanical assist. Despite this, a Certified Nursing Assistant (CNA) used a sit-to-stand lift for the transfer, contrary to the resident's care plan and facility policy. This action was confirmed through interviews with the CNA and the Nursing Home Administrator, as well as review of the resident's care plan and facility policy.
Failure to Maintain Advance Directive for Resident
Penalty
Summary
The facility failed to formulate and maintain an advance directive for Resident 185, which is a requirement to honor the resident's right to request, refuse, and/or discontinue treatment. Upon admission, the facility's policy mandates that a licensed nurse or social worker discuss options such as Cardiopulmonary Resuscitation (CPR) or Do-Not-Resuscitate (DNR) orders with the resident or their legal representative and obtain the corresponding physician orders. However, during the survey, it was found that Resident 185 did not have any orders for CPR or DNR on file, nor was there a Provider Orders for Scope of Treatment (POST) form available in the resident's hard charts or electronic records. Interviews with facility staff, including a Registered Nurse and a Quality Consultant, revealed that the usual process for determining a resident's CPR or DNR status involved checking the most recent signed orders in the hard charts. Despite this, no such orders were found for Resident 185, and the staff acknowledged that the necessary documentation was not accessible. Although there were hospital transfer documents indicating the resident's DNR status, these were not placed in a location where staff would typically look during an emergency. The Quality Consultant confirmed that the DNR orders were not in the expected location and took steps to contact the hospital for the necessary documentation.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as observed during a medication administration task. The surveyor noted 2 errors out of 27 medication opportunities, resulting in an error rate of 7.41%. This deficiency affected one resident, who received two insulin injections using injectable pens that were not properly primed according to the manufacturer's instructions. The insulin pens used were Basaglar Kwikpen (insulin glargine) and Insulin Aspart, both requiring priming to ensure accurate dosing. During the observation, a registered nurse (RN) did not prime the insulin pens before administering the doses to the resident. The RN was unaware of the need to prime the pens, indicating a lack of training or knowledge regarding the proper procedure. The Director of Nursing (DON) was also uncertain about the facility's policy on insulin pen use and whether priming was necessary, although they later acknowledged the manufacturer's instructions were not followed. This oversight in medication administration procedures led to the identified deficiency.
Deficiencies in Food Safety and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage, preparation, distribution, and serving of food. Surveyors observed that potentially hazardous foods were not served at appropriate temperatures, which could increase the risk of illness for residents. During the survey, it was noted that food items such as pureed lasagna were served at temperatures below the required 135 degrees Fahrenheit. The Dietary Aide recorded a temperature of 128 degrees Fahrenheit for the pureed lasagna, which was not reheated before being served to residents on a pureed diet. This oversight affected two residents who were served the pureed meal without the necessary temperature adjustments. Additionally, the facility did not cover food items while transporting room trays through hallways and past resident rooms. Observations included uncovered bowls of cereal, juice, and coffee being delivered to residents' rooms by an LPN, who walked significant distances with the exposed food. This practice was contrary to the facility's expectations, as stated by the Dietary Manager, who acknowledged that food should be covered when transported outside of the holding cart. These deficiencies in food handling and transportation practices were identified during the survey, highlighting lapses in maintaining food safety standards.
Resident Fed in Undignified Manner
Penalty
Summary
The facility did not assist one resident with eating in a dignified manner. The resident, who is dependent on staff for eating, was observed being fed by a Certified Nursing Assistant (CNA) who repeatedly wiped food from the resident's lower lip and chin with a spoon and then fed the food back to the resident. This practice was observed during both lunch and breakfast on separate days. The CNA indicated that she was not aware that using a spoon to wipe food from a resident's face and refeeding it to them was undignified and had not been instructed otherwise. The Director of Nursing (DON) confirmed that it is inappropriate for staff to wipe residents' chins or lips with a spoon and re-feed them due to dignity and infection control reasons. The facility's policy on Meal Service Standards, which emphasizes serving residents in a dignified and courteous manner, was not followed in this instance. The DON indicated that staff reeducation would be initiated to address this issue.
Failure to Provide Adequate Assistance with Meals for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment received the necessary assistance with meals to maintain good nutrition. The resident, who has Alzheimer's disease and other significant health issues, was observed struggling to eat independently during multiple meal times. Despite the resident's care plan and speech therapy recommendations indicating the need for verbal cues and physical assistance during meals, staff provided minimal assistance and did not offer alternative foods or fluids when the resident did not consume the provided meal. During lunch, the resident was observed eating only a small portion of the meal and engaging in inappropriate eating behaviors, such as pouring juice over the meal and attempting to drink milk with a spoon. Staff made only one attempt to assist the resident and did not offer any alternative foods or fluids. Similarly, during breakfast, the resident was left unattended for extended periods, and staff did not provide timely assistance or offer alternative foods. The resident consumed very little of the meal and was not given additional fluids or finger foods despite the care plan's instructions. Interviews with staff revealed a lack of consistent and adequate assistance for the resident during meals. The Certified Dietary Manager was unaware of the specific issues observed and stated that finger foods and double breakfasts were provided, but these were not observed during the survey. The Registered Dietitian and Speech Therapist confirmed the resident's need for assistance and direction during meals. The Director of Nursing and a Registered Nurse acknowledged the deficiency and indicated plans to educate staff and address the issue immediately.
Failure to Conduct Trauma-Informed Assessment and Care Planning
Penalty
Summary
The facility failed to comprehensively assess a resident (R31) for trauma-informed care and develop care plan approaches to mitigate any triggers to prevent re-traumatization. The facility's policy on providing culturally competent and trauma-informed care requires a multi-faceted approach to identifying resident history of trauma and cultural preferences, including the use of various assessment tools. However, the surveyor found that no trauma-informed assessment was conducted for R31, who is a military veteran with diagnoses including PTSD, alcohol dependence in remission, bipolar disorder, and other mood disorders. R31 reported no recollection of any facility staff discussing his history or potential stress triggers with him. The Assistant Nursing Home Administrator (ANHA) confirmed that a comprehensive trauma-informed assessment was not completed for R31, and thus no care plan was developed to address potential triggers. Although the ANHA mentioned having a conversation with R31 about his diagnosis and potential triggers, there was no documentation of this discussion in R31's record. The lack of a comprehensive assessment and care plan for R31, despite his significant history of trauma and related diagnoses, constitutes a deficiency in providing trauma-informed care as per the facility's policy.
Improper Timing of Insulin Administration
Penalty
Summary
The facility did not provide pharmaceutical services to meet the needs of a resident reviewed for insulin administration. Specifically, a registered nurse (RN) administered 10 units of Insulin Aspart (Humalog) to the resident's right arm at 6:59 AM, but the resident did not begin eating their meal until 7:57 AM, which was 58 minutes after the insulin was given. This timing is inconsistent with guidelines that rapid-acting insulins should be administered within 0-15 minutes before a meal or immediately following a meal to optimize blood sugar control. During an interview, the RN acknowledged that she thought the meal would be served around 7:30 AM and admitted that she should have ensured the insulin was administered closer to the meal time. The Director of Nursing (DON) confirmed that the expectation is for rapid-acting insulin to be administered within 5-10 minutes of a meal or right after. The surveyor explained the observation to the DON, who stated that she would address the issue with education.
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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