Pleasant View Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, Wisconsin.
- Location
- N3150 Wi-81, Monroe, Wisconsin 53566
- CMS Provider Number
- 525643
- Inspections on file
- 25
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Pleasant View Nursing Home during CMS and state inspections, most recent first.
A resident’s APOA signed a consent form requesting an influenza vaccination in accordance with facility policy, which requires consent prior to vaccine administration and placement of the consent in the medical record. However, review of the resident’s electronic health record showed no documentation that the flu vaccine was administered, refused, or that education was provided. During interviews, the DON confirmed that only the consent could be found and acknowledged that the expectation would be that the vaccine was administered when a signed consent is present.
A resident over age 65 on hospice care, with severe dementia, HTN, atherosclerotic heart disease, and supraventricular tachycardia, had prior COVID-19 vaccinations and had POA consent documented for both COVID-19 and influenza vaccines. The resident received the influenza vaccine, but there was no record that the 2025–2026 COVID-19 vaccine was administered or declined, despite facility policy requiring education, offering, and documentation of COVID-19 vaccination for eligible residents. During interview, the DON confirmed there was no documentation of administration or refusal of the COVID-19 vaccine for this resident.
The facility did not complete annual performance evaluations for five CNAs within the required 12-month timeframe. All evaluations were conducted on the same day during the survey, and the DON confirmed that these were completed after surveyors arrived, in violation of facility policy.
A staff member witnessed a resident being slapped and verbally threatened by a family member, but the incident was not immediately reported to the administrator or designee as required. Instead, the staff member left a written statement under a supervisor's door, resulting in a delay in reporting. Facility policy on immediate abuse reporting was not followed, and there was no documented verification that staff received required abuse reporting education.
Two residents with severe cognitive impairment and dementia were subjected to involuntary seclusion by staff. In one case, a CNA blocked a fire door with a mechanical lift to restrict a resident's movement, and in another, a RA confined a resident to her room and shut the door after an episode of agitation. Both actions were contrary to facility policy and resulted in the residents being separated from others against their will.
A resident with severe cognitive impairment and a history of aggressive behavior was involved in multiple incidents of physical aggression towards other residents. Despite the facility's policy to prevent abuse, interventions were inconsistent and insufficient, leading to repeated altercations. The care plan did not adequately address known triggers or provide effective interventions to prevent further incidents.
A resident with cognitive impairment struck another resident with a walker, but the incident was not reported to the state agency as required. Despite staff witnessing and documenting the event, it was not reported due to a misunderstanding of reporting requirements, as staff believed the absence of pain or injury negated the need for reporting.
A facility failed to thoroughly investigate an incident of potential resident-to-resident abuse. A resident with severe cognitive impairment struck another resident with a fist after a mobility issue. Although immediate interventions were implemented, the investigation lacked additional staff interviews, witness statements, and assessments of other residents' safety perceptions, violating the facility's policy on abuse investigations.
The facility failed to ensure medication availability for two residents, leading to missed doses. One resident with chronic obstructive pulmonary disease missed doses of Combivent due to unavailability, while another resident missed doses of Famotidine, Prednisone, and Sertraline. Agency nurses lacked access to the Omnicell system, contributing to the deficiency.
Three residents with severe cognitive impairments were involuntarily secluded behind a wall in a facility, isolating them from other residents and activities. The wall was erected to prevent wandering, but families were not informed, leading to distress. Staff believed it provided safety, but families were shocked by the lack of interaction and stimulation.
The facility failed to maintain a sanitary environment for food preparation and dishwashing, affecting all 64 residents. The kitchen floor was unclean, and the dishwashing machine did not reach the required rinse temperature. Logs for sanitizer testing and dishwasher temperatures were incomplete. Staff shortages and maintenance issues contributed to these deficiencies.
Three residents were moved within the facility without being given the opportunity to refuse the transfer, despite the facility's policy allowing for such refusal. The residents, all severely cognitively impaired, were moved to a different unit without their families being adequately informed of their right to refuse. The facility justified the moves as necessary due to staff supervision gaps, but failed to communicate this right to the families verbally.
A resident's bathroom was observed to be soiled with stool over several days, despite the facility's claim of daily cleaning. The resident's family reported having to clean the room themselves due to the facility's inaction. Housekeeping staff were unaware of the need for cleaning, and the NHA stated the bathroom had been cleaned.
The facility failed to notify the Ombudsman and provide complete discharge notices for two residents with Alzheimer's, omitting transfer locations and appeal rights. Families were shocked and unaware of their right to appeal.
The facility failed to provide an ongoing program of activities for three residents on the Way Unit, as required by their care plans. Despite having severe cognitive impairments and specific activity preferences, these residents were not documented as participating in or being offered activities. Interviews with staff revealed confusion about responsibility for activities, and no documentation was available to show activities were offered or declined.
The facility failed to provide sufficient qualified nursing staff on the Way Unit, leaving Resident Assistants (RAs) without Certified Nursing Assistants (CNAs) to care for residents requiring increased supervision. RAs, who were not CNAs, worked alone and were unable to perform hands-on care or manage emergencies effectively. The Nursing Home Administrator confirmed the lack of CNAs and reliance on a phone system for assistance, which was inadequate. This staffing issue compromised resident safety and well-being.
The facility failed to provide adequate supervision and safety, leading to multiple incidents involving residents. A resident fell during an improper transfer, another was transported unsafely in a wheelchair, and several residents with aggressive tendencies were left unsupervised, resulting in altercations. Staff did not consistently follow care plans and facility policies, contributing to these deficiencies.
The facility failed to follow care protocols for two residents. One resident did not receive required neurological checks after a fall, and another resident was not weighed daily as ordered, with the physician not consistently informed of significant weight changes. Interviews revealed inconsistencies in the facility's process for obtaining and documenting weights.
A resident with hemiplegia received care from a CNA and DON who failed to follow proper hand hygiene and infection control practices. The CNA did not wash hands upon entering the room, used the same gloves for multiple tasks, and did not disinfect surfaces after use. The DON did not notice these lapses during the care. The facility's hand hygiene policy was not followed, resulting in deficiencies.
A long-term care facility failed to provide adequate supervision and safety measures, leading to a resident with Alzheimer's disease eloping through an alarmed door and being found at the bottom of a stairwell. The facility also did not effectively manage wandering behaviors, as several residents reported uninvited entries into their rooms by other residents. Additionally, a resident's leg was injured due to improper wheelchair use. These incidents highlight deficiencies in the facility's supervision and safety protocols.
The facility failed to maintain an effective infection prevention and control program, affecting all residents. Staff returned to work too soon after GI symptoms, contrary to CDC guidelines. Additionally, a resident was observed accessing the ice machine with bare hands, violating infection control protocols.
Several residents reported grievances about a wandering resident entering their rooms and taking belongings, but the facility failed to follow its grievance process. Staff were aware of the concerns but did not report them to management or document the incidents, leading to unresolved grievances and a lack of accountability.
A facility failed to store and label medications properly, leading to the administration of expired medications to residents. A nurse administered expired Betaxolol eye drops to a resident with glaucoma, and expired acetaminophen was given to two residents for chronic pain. Additionally, an opened Tubersol vial with an unreadable date was found, indicating lapses in checking expiration dates.
A resident with moderate cognitive impairment expressed concerns about staff not consistently making her bed and failing to provide meal substitutions as requested. Despite the facility's policy, the resident waited 40 minutes for a replacement muffin, which was only provided after surveyor intervention. This affected the resident's quality of life and nutritional intake.
A resident was observed with medications on the floor and an empty medication cup, indicating a failure to ensure safe self-administration. The facility's policy requires a physician's order for self-administration, which the resident did not have. An LPN left medications in the resident's room without verifying the order, and the resident reported taking the pills after picking them up from the floor. Interviews with staff confirmed that this practice was unsafe and not in line with facility policies.
A facility failed to conduct a comprehensive sleep assessment before prescribing Lemborexant, a hypnotic medication, to a resident with insomnia. Despite the resident's history of sleep issues, the care plan lacked specific interventions for sleep monitoring, and no sleep tracking was documented. The facility's policy requires a comprehensive review before prescribing psychotropic medications, which was not followed in this case.
A resident was not offered the PCV20 pneumococcal vaccine as recommended by the CDC, despite the facility's policy requiring assessment and offering of the vaccine upon admission. The resident's medical record lacked documentation of education on the vaccine's benefits and side effects, as well as consent or declination. The infection preventionist confirmed the oversight, leading to incomplete pneumococcal vaccinations for the resident.
Lack of Documentation and Administration of Influenza Vaccination After Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was offered and received an influenza vaccination, and that the resident’s medical record contained documentation of administration, refusal, or education regarding the vaccine. The facility had a written Influenza Vaccination policy dated 7/1/25 stating that individuals receiving the influenza vaccine, or their legal representative, must provide consent prior to administration and that the consent would be located in the resident’s medical record. For one resident (R4), the Activated Power of Attorney (APOA) signed the facility’s Influenza Vaccination Information and Release Form on 10/2/25, indicating that they had read information about influenza and the flu vaccine, understood the benefits and risks, and requested that the influenza vaccine be given to the resident named on the form. Despite the signed consent, surveyor review of R4’s electronic health record revealed no documentation that the influenza vaccination was administered, nor any record of refusal or education. During an interview on 3/23/26, the DON stated that they had located the consent but were still looking for documentation that the vaccine had been given. On 3/24/26, the DON reported they were unable to find any documentation indicating that R4 had received the influenza vaccination. When asked if the expectation would be that the vaccine was administered when a signed consent was present, the DON confirmed that this was the expectation.
Failure to Administer or Document 2025–2026 COVID-19 Vaccination for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that when COVID-19 vaccine was available, each resident was offered and either administered or documented as declining the 2025–2026 COVID-19 vaccine, in accordance with facility policy and CDC/FDA guidance. The facility’s COVID-19 Vaccination policy, implemented 11/10/25, states that residents and staff are to be educated and offered the COVID-19 vaccine, and that vaccinations will be offered when supplies are available unless medically contraindicated, already administered during the time period, or refused. For adults 65 years and older who were previously vaccinated, the policy references a schedule requiring administration of two doses of the 2025–2026 vaccine. One resident, R3, over the age of 65 with severe unspecified dementia with agitation, primary hypertension, atherosclerotic heart disease, and supraventricular tachycardia, was admitted on hospice with an activated POA. R3 had prior COVID-19 vaccinations in 2021 and 2023. A progress note dated 9/29/25 documented that the resident’s daughter/POA agreed to both COVID-19 and influenza vaccines, and that hospice would be contacted for approval. The resident subsequently received the influenza vaccine on 10/27/25, but there was no documentation that the 2025–2026 COVID-19 vaccine was administered or declined. During an interview on 3/24/26, the DON stated she was unable to find any information indicating that the COVID-19 vaccine had been given to or refused by this resident and stated she would have expected the resident to receive the vaccine after verbal consent from the POA, confirming the lack of documentation and follow-through on the COVID-19 vaccination for R3.
Failure to Complete Timely Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for all Certified Nursing Assistants (CNAs) within the required 12-month period, as mandated by facility policy. Specifically, five CNAs did not have their annual performance evaluations completed on time. For each CNA reviewed, the most recent annual evaluation was not conducted until after the 12-month period had elapsed. The evaluations for all five CNAs were completed on the same day, which coincided with the surveyor's visit. During the survey, the Director of Nursing (DON) confirmed that the evaluations were completed after the surveyors arrived at the facility. The DON also acknowledged that annual performance evaluations are required every 12 months, as per facility policy. The surveyor's review of records and interviews with the DON confirmed that the evaluations had not been performed in a timely manner prior to the survey.
Failure to Timely Report Alleged Abuse to Proper Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported to the appropriate authorities in accordance with state law and facility policy. Specifically, a staff member witnessed an incident in which a resident's wife yelled at and slapped the resident, then grabbed his face and made a threatening statement. The staff member wrote a statement about the incident approximately one hour after witnessing it and left it under a supervisor's door, as instructed by her supervisor. However, the supervisor was not present for four days, resulting in a delay in reporting the incident to the administrator or designee. Interviews and record reviews revealed that the facility's procedures for immediate reporting were not followed. The facility policy requires that all allegations of abuse be reported immediately, but not later than two hours after the allegation is made, to the administrator and other required agencies. The staff member did not directly notify the administrator, DON, or social services supervisor, and the education provided to staff regarding abuse reporting was not documented or verified for completion, particularly among agency staff. This lapse led to a failure in timely reporting and documentation as required by both facility policy and state regulations.
Failure to Prevent Involuntary Seclusion of Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents from involuntary seclusion, as evidenced by two separate incidents involving residents with severe cognitive impairment and a history of dementia and agitation. In the first case, a resident identified as an elopement risk and known to wander was found to have been intentionally restricted from accessing certain areas. An agency Certified Nursing Assistant (CNA) closed one side of a fire door and blocked the other side with a mechanical lift, effectively confining the resident to a specific area to prevent entry into other residents' rooms. This action was observed by the Maintenance Assistant, who immediately reported the obstruction. In the second incident, another resident with Alzheimer's disease and a history of physical aggression was subjected to involuntary seclusion by a Resident Assistant (RA). The RA was observed by two staff members taking the resident to her room and shutting the door after the resident became agitated and physically aggressive. The resident was heard yelling for help, and another CNA intervened to assist her. Prior to the incident, the resident had been sitting quietly at the nurses' station, and the RA's actions were attributed to anger over the resident's earlier behaviors. Both residents involved were severely cognitively impaired, ambulatory, and wore wander guard alarms. The facility's own policies defined involuntary seclusion as separating a resident from others or confining them to their room against their will, except in short-term, monitored, therapeutic situations. In both cases, staff actions did not align with these guidelines, resulting in the residents being involuntarily secluded.
Failure to Prevent Resident-to-Resident Aggression
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving a resident with significant cognitive impairment and a history of aggressive behavior. This resident, diagnosed with Alzheimer's disease, anxiety disorder, and severe dementia with agitation, was involved in three separate incidents of physical aggression towards other residents. Despite the facility's policy to prevent abuse and neglect, the interventions in place were inconsistent and insufficient to prevent these occurrences. In the first incident, the resident struck another resident on the shoulder while trying to navigate through a crowded area. The staff member present witnessed the event but was unable to intervene in time to prevent the physical contact. The second incident involved the same resident striking another resident in the arm when unable to maneuver around a wheelchair in the hallway. This incident was witnessed by staff, but it was not reported to the state agency or investigated as abuse due to the perceived lack of willful intent. The third incident occurred when the resident struck another resident on the shoulder, prompting immediate separation and one-to-one supervision. Despite these repeated incidents, the facility's care plan for the aggressive resident did not adequately address the known triggers or provide effective interventions to prevent further altercations. The facility's failure to update the care plan and implement consistent interventions resulted in ongoing resident-to-resident aggression.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the state survey agency within the required timeframe. The incident involved two residents, one of whom, R3, with significant cognitive impairment, struck another resident, R11, with a walker. Despite the incident being witnessed by staff and documented, it was not reported to the state agency or investigated as required by the facility's policy. R3, who has Alzheimer's disease and other cognitive impairments, was observed striking R11, who also has significant cognitive impairment, with a walker. The incident occurred when R3 was unable to maneuver around R11's wheelchair. Although the incident was documented and the physician and family were informed, it was not reported to the state agency. Staff interviews revealed a misunderstanding of the reporting requirements, with some staff believing that the absence of pain or injury negated the need for reporting. The facility's policy mandates immediate reporting of abuse allegations, but this was not adhered to in this case. Interviews with the Administrator and Social Services Director indicated a lack of clarity regarding what constitutes reportable abuse, particularly in cases involving residents with cognitive impairments. Despite staff training on abuse reporting, the incident was not reported due to a perceived lack of injury or willful intent, highlighting a gap in the facility's compliance with reporting protocols.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident of potential resident-to-resident abuse involving two residents. One resident, with severe cognitive impairment and a history of behaviors such as pacing and combativeness, struck another resident with a fist after being unable to maneuver her walker around the other resident's wheelchair. The incident was documented, and immediate interventions were put in place, such as assigning one-on-one staff supervision to the aggressive resident. However, the investigation was incomplete as it lacked additional staff interviews, witness statements from other residents or visitors, and did not assess whether other residents felt safe. The facility's policy on abuse, neglect, and exploitation requires a comprehensive investigation when such incidents occur, including identifying and interviewing all involved parties and documenting the investigation thoroughly. Despite this policy, the investigation into the incident was insufficient. Interviews with staff revealed that while they were aware of the reporting process, the investigation did not include follow-up interviews or statements from other potential witnesses, nor did it assess the safety perceptions of other residents. This lack of thorough investigation into the resident-to-resident abuse incident constitutes a deficiency in the facility's handling of the situation.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure the availability of medications for two residents, R6 and R9, leading to missed doses. R6, who was admitted with chronic obstructive pulmonary disease and other conditions, had an order for Combivent Respimat Inhalation Aerosol Solution to be administered four times daily. However, the medication was not available on multiple occasions, resulting in missed doses on several days. Documentation in the electronic medical record (EMR) indicated that the inhaler was not found or not available, and there were delays in reordering and receiving the medication from the pharmacy. Similarly, R9, admitted with diagnoses including essential hypertension and anxiety, had orders for Famotidine, Prednisone, and Sertraline. These medications were not administered on several occasions due to unavailability, despite being stocked in the facility's Omnicell system. Progress notes indicated that the medications were on order or waiting for delivery, but there was a lack of access to the Omnicell system by agency nurses, which contributed to the delay in medication administration. Interviews with staff revealed that agency nurses were not given access to the Omnicell system, which contained the necessary medications. This lack of access, combined with issues in the medication ordering process through the EMR, led to the deficiency. The Director of Nursing confirmed that the facility had an Omnicell system and that regular nurses had access, but agency nurses did not, which contributed to the residents missing their medications.
Involuntary Seclusion of Residents Behind Erected Wall
Penalty
Summary
The facility failed to ensure that three residents were free from involuntary seclusion, as they were moved from their original unit to a different unit within the facility and placed behind a wall. This wall was erected to keep the residents from wandering off the unit, effectively isolating them from other residents and activities. The families of these residents were not informed about the wall or the isolation, leading to distress and confusion among family members when they discovered the situation. The residents involved had severe cognitive impairments and various diagnoses, including Alzheimer's Disease, dementia, and other related conditions. Their care plans indicated a need for social interaction and activities, which were not provided in the secluded area. The facility's actions were reportedly taken to manage resident-to-resident incidents and wandering behaviors, but the method of isolation was not communicated transparently to the families. Interviews with staff and family members revealed a lack of awareness and understanding of the situation. Some staff members believed the wall provided a safer environment for the residents, while family members expressed shock and concern over the lack of interaction and stimulation for their loved ones. The facility's decision to erect the wall was made by the interdisciplinary team, but it was not adequately communicated to or agreed upon by the residents' families.
Deficiencies in Kitchen Sanitation and Dishwashing Procedures
Penalty
Summary
The facility was found to have deficiencies in maintaining a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 64 residents. Observations revealed that the kitchen floor was unclean, with visible dirt and food debris, and the tile flooring near the drain had cracks and gouges. The facility's policy requires regular cleaning of kitchen and dining areas, but interviews with dietary aides indicated that the floors were not being cleaned adequately, and the kitchen was only mopped and swept on specific days. The dietary aide also mentioned a shortage of staff, which contributed to the lack of cleanliness. The dishwashing machine was not reaching the required rinse temperature of 180 degrees Fahrenheit, as evidenced by the temperature logs. The logs showed multiple instances where the final rinse temperature was below the required level, and corrective actions were taken by running the dishes twice. Interviews with dietary aides and maintenance staff revealed that the dish machine had been experiencing issues for about two weeks, and the maintenance team was aware of the problem. The facility's policy mandates that dishwashing machines using hot water for sanitization must maintain specific temperatures, and any inadequacies should be reported and corrected immediately. The facility's logs for sanitizer testing and dishwasher temperatures were incomplete, with several entries left blank. The nursing home administrator acknowledged that the dish machine was not functioning correctly and that the logs were incomplete. Maintenance staff indicated that a boiler issue was preventing the water from reaching the necessary temperature for proper dish sanitization. The dietary manager confirmed that the floors were not being cleaned as required and that a new staff member was being trained for deep cleaning tasks. Overall, the facility failed to adhere to its policies for maintaining a sanitary environment and ensuring proper dish sanitization.
Failure to Uphold Residents' Right to Refuse Room Transfers
Penalty
Summary
The facility failed to uphold the residents' right to refuse room transfers, as evidenced by the cases of three residents who were moved without being afforded the opportunity to refuse the transfer. The facility's policy on room changes, revised in March 2021, states that residents have the right to refuse room changes unless the move is necessary for specific reasons, such as relocating between skilled and non-skilled nursing units or for staff convenience. However, in the cases of the three residents, the facility initiated room transfers without adequately informing the residents' representatives of their right to refuse. Resident 1, who is severely cognitively impaired with a BIMS score of 0, was moved to a different unit without the family being given a clear explanation or the right to refuse the transfer. The family was contacted late on a Friday and was told to sign paperwork by Monday, with the move occurring early that morning. Similarly, Resident 2, also severely cognitively impaired, was moved without the family being informed of their right to refuse. The family was contacted while on vacation and was told the move was to prevent incidents, but they were not given the option to refuse the transfer. Resident 3, who also has severe cognitive impairment, was moved under similar circumstances. The facility's social worker stated that the right to refuse was included in the paperwork, but the families reported not being informed of this right. The Nursing Home Administrator justified the moves as necessary due to staff supervision gaps and stated that the right to refuse was written on the form, but the families were not adequately informed verbally. This lack of communication and failure to uphold residents' rights constitutes a deficiency in the facility's handling of room transfers.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, identified as R2, as evidenced by the condition of R2's bathroom. On multiple occasions, a surveyor observed that R2's toilet was soiled with stool, and this condition persisted over several days. R2's family member reported that the bathroom had been in this state for several days and that they had to clean the room themselves due to the facility's inaction. Housekeeping staff, when interviewed, stated that rooms are usually cleaned daily but were unaware of the specific need to clean R2's bathroom. The Nursing Home Administrator claimed that the bathroom had been cleaned, despite evidence to the contrary.
Failure to Notify Ombudsman and Provide Complete Discharge Notices
Penalty
Summary
The facility failed to properly notify the Office of the State Long-Term Care Ombudsman of two facility-initiated discharges and did not ensure that the written notices contained all necessary information. The notices for two residents, who were both severely cognitively impaired with Alzheimer's Disease, did not include the location to which the residents were to be transferred or discharged, a statement of the residents' appeal rights, or the contact information for the entity that handles such appeals. Despite the facility's claim that the notices were sent to the Ombudsman, the Ombudsman reported not receiving them. The first resident, who had a history of behavioral symptoms and was dependent on assistance for daily activities, was given a 30-day discharge notice due to the facility's inability to safely care for her. The notice lacked specific details about the transfer location and appeal rights. The resident's family was shocked by the decision and expressed concerns about the impact of the move on the resident's quality of life. The facility's social worker and nursing home administrator both stated that the decision was made because the resident no longer required skilled nursing care, but the family was not informed about their right to appeal the decision. The second resident, also severely cognitively impaired, was issued a similar 30-day discharge notice. The notice was missing critical information, including the transfer location and appeal rights. The resident's family was upset and surprised by the facility's decision, which was attributed to the resident's involvement in incidents with other residents. The facility's staff claimed that the resident would be better served in a dementia-specific placement, but the family was not made aware of their right to appeal the discharge. The Ombudsman confirmed that they did not receive the required notices for either resident.
Failure to Provide Activities for Residents on Way Unit
Penalty
Summary
The facility failed to provide an ongoing program to support resident choice of activities based on comprehensive assessments and care plans for three residents residing on the Way Unit. The activity staff and other staff working on the Way Unit did not provide or offer activities to these residents, and there was no documentation of their participation or being offered activities since their relocation to the unit. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyor. Resident 1, who has severe cognitive impairment and various diagnoses including Alzheimer's Disease and depression, was not documented as having participated in or declined activities. The resident's care plan indicated a preference for simple, structured activities and required staff assistance for participation. Similarly, Resident 2, also severely cognitively impaired, had no documentation of activity participation or declination. This resident's care plan emphasized engagement in simple activities and required assistance with decision-making. Resident 3, with advanced Alzheimer's and other mental health conditions, was noted to have limited participation in activities, with staff attempting new approaches without documented success. Interviews with activity staff and CNAs revealed a lack of clarity and responsibility regarding the provision and documentation of activities for these residents. Activity staff were unaware of any activities being conducted on the Way Unit, and CNAs were uncertain about their role in facilitating activities. The Nursing Home Administrator and Business Office Manager were unable to provide documentation of activities being offered or declined by the residents, highlighting a systemic issue in the facility's activity program management.
Insufficient Qualified Nursing Staff on Way Unit
Penalty
Summary
The facility failed to ensure sufficient, qualified nursing staff were available at all times to meet the needs of residents, specifically for three residents who required increased supervision. Resident Assistants (RAs), who were not Certified Nursing Assistants (CNAs), were left to work alone on the Way Unit, which housed these residents. The facility's staffing schedule showed multiple instances where RAs worked without a CNA present, despite the residents' need for increased supervision and care. Interviews with staff and family members confirmed that RAs were working alone and were not equipped to provide hands-on care, as they lacked the necessary certification and training. The Nursing Home Administrator acknowledged that the RAs were not CNAs and could not perform physical care, relying instead on a phone system to call for assistance from another unit. However, there were instances where calls for help went unanswered, leaving the RAs unable to manage emergencies effectively. The RAs expressed concerns about the safety of the residents and their ability to provide adequate supervision, especially when all residents were awake and required line-of-sight monitoring. The facility's failure to assign a CNA to the Way Unit compromised the safety and well-being of the residents, as the RAs were not trained in dementia care or managing behaviors, and the unit was understaffed.
Inadequate Supervision and Safety Measures in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for several residents, leading to multiple incidents. One resident, who required a two-person transfer with a full body lift, was transferred independently by a staff member, resulting in a fall. Another resident was transported without foot pedals on their wheelchair, causing their leg to drag under the seat, and was transferred to the toilet without the use of a gait belt as per their care plan. Additionally, a resident was observed self-transferring without appropriate footwear, and another was transferred using an incorrect sling size, which was not suitable for their weight. The facility also failed to provide adequate supervision for residents with a history of aggressive behavior related to dementia. Several residents were observed in common areas or activities without staff within line of sight, despite care plans indicating the need for monitoring due to potential aggression. This lack of supervision led to multiple resident-to-resident altercations, including incidents where residents hit or grabbed each other, resulting in physical confrontations. The facility's policies and care plans were not consistently followed by staff, contributing to the deficiencies. Staff failed to adhere to protocols for using mechanical lifts, transferring residents, and monitoring those with aggressive tendencies. These lapses in following established procedures and care plans resulted in unsafe conditions and increased the risk of accidents and resident-to-resident incidents.
Failure to Follow Care Protocols for Neurological Checks and Weight Monitoring
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards and the comprehensive person-centered care plan for two residents. Resident 8, who has severe cognitive impairment and is dependent on staff for transfers, experienced an unwitnessed fall. According to the facility's protocol, neurological checks should have been conducted at specific intervals following the fall. However, the checks were not completed as required, with significant gaps in the monitoring schedule, and the facility did not adhere to its protocol. Resident 4, who has diagnoses including congestive heart failure and chronic pain, was admitted with orders to be weighed daily and to notify the physician of any significant weight changes. The facility failed to obtain daily weights as ordered, and the physician was not consistently informed of weight changes that exceeded the specified parameters. The documentation shows multiple instances where weights were not recorded, and the facility did not follow the physician's orders for daily monitoring. Interviews with the Director of Nursing and staff revealed inconsistencies in the process of obtaining and documenting weights. The facility's standard practice was not followed, and there was a lack of communication regarding resident refusals and significant weight changes. The failure to adhere to the care plan and physician's orders resulted in deficiencies in the care provided to both residents.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices were followed, as observed during the care of a resident with hemiplegia secondary to a cerebrovascular accident. The resident, who is dependent on staff for care and transfers, was receiving personal care from a CNA and the Director of Nursing (DON). The CNA did not perform hand hygiene upon entering the resident's room and proceeded to apply gloves and perform peri care without washing hands. After completing the peri care, the CNA did not remove gloves or perform hand hygiene before continuing to use the same gloves to handle clean washcloths and rinse the resident. The CNA further compromised infection control by placing dirty washcloths in the clean wash basin and on the bedside table, and by not disinfecting these surfaces or the mechanical lift after use. The CNA continued to use the same soiled gloves to apply barrier cream to the resident and to brush the resident's hair, failing to perform hand hygiene at any point during these tasks. The DON, who was present during the care, did not notice the missed hand hygiene opportunities or the improper handling of washcloths and did not intervene. Upon interview, the CNA acknowledged the failure to perform hand hygiene and disinfect surfaces, while the DON admitted to not realizing the lapses in infection control practices during the care. The facility's policy on hand hygiene, which emphasizes its importance in preventing the spread of infections, was not adhered to, leading to the observed deficiencies in infection control practices.
Inadequate Supervision and Safety Measures in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents, particularly for a resident with a history of elopement and exit-seeking behaviors. This resident, who has Alzheimer's disease and moderate cognitive impairment, was able to exit through an alarmed door and was found at the bottom of a stairwell. The door alarm had sounded for 15 seconds, but staff did not respond promptly due to a malfunctioning alert board and lack of staff presence in the immediate area. This incident led to a finding of Immediate Jeopardy. Additionally, several residents expressed concerns about wandering residents entering their rooms uninvited. One resident, who is not cognitively intact, was not provided with any protective measures such as a stop sign to prevent another resident from entering her room. Staff were aware of these concerns but did not implement effective interventions to address them. The facility's failure to adequately supervise and manage wandering behaviors contributed to the ongoing issues. Furthermore, the facility did not ensure proper use of equipment, as evidenced by a resident whose leg got caught under a wheelchair due to the absence of foot pedals. The facility's policies on falls and wandering were not effectively implemented, as staff failed to document and monitor interventions adequately. These deficiencies highlight the facility's inability to maintain a safe environment for its residents.
Removal Plan
- Staff in nursing, life enrichment, housekeeping, and maintenance were educated regarding the intervention to have line of sight supervision when resident indicates that he is exit-seeking and the need to call maintenance immediately if there are issues identified with the Wander Guard or call light system.
- All resident care plans were reviewed for individuals with identified wandering/elopement concerns. All elopement assessments are up to date as are all of the assessments for new residents that would have put them into this category.
- The interventions were reviewed for adequacy to meet safety needs and to determine if all increased supervision needs were being met. No other care plans were identified where increased supervision was listed as an intervention.
- The policy for managing care plan interventions regarding wandering and exit-seeking was changed to include monthly reviews of all plans, or sooner if elopement occurs, by the clinical team which includes DON, nursing management, and social services.
- Daily audits of the delayed egress door system functionality were implemented.
- The procedure for notifying maintenance regarding the failure of the elopement prevention system has been updated to include notification immediately to prevent elopement.
- Education was provided on the facility's elopement prevention program listing the names and pictures of the individuals who are high risk for elopement on each unit. Staff have been educated/reeducated on the program and their roles.
- DON or DON designee will audit the care plan interventions for proper practice and implementation on a daily basis for one week, then weekly for a month, then monthly for three months, then quarterly.
- Action and reeducation will take place promptly upon discovery if it is discovered that interventions are not being properly employed.
- Maintenance supervisor will review the WorxHub system for work orders regarding the elopement prevention system that are not being reported promptly on a daily basis for one week, then weekly for one month, and monthly for three months, then quarterly. Action and education will take place promptly if policy is not followed.
- Results will be presented to QAPI.
Inadequate Infection Control and Staff Return-to-Work Practices
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, which has the potential to affect all 69 residents. The deficiency was identified through interviews and record reviews, revealing that staff returned to work too soon after experiencing gastrointestinal (GI) symptoms. The facility's policy on communicable diseases states that personnel with active infections should not be in contact with residents or their environments until they are no longer contagious. However, the infection preventionist (IP) was found to be using incorrect criteria for determining return-to-work dates, allowing staff to return on the last symptom date instead of adhering to CDC guidelines, which recommend a 48 to 72-hour symptom-free period before returning to work. Additionally, the facility's surveillance for infections policy requires ongoing monitoring of healthcare-associated infections and adherence to infection prevention practices. Despite this, the facility's staff line lists from March to June 2024 showed multiple instances where staff with GI symptoms returned to work on the last symptom date, contrary to CDC guidelines. The infection preventionist admitted to completing the well dates incorrectly and acknowledged the need for a new process to ensure compliance with the guidelines. Furthermore, surveyors observed a resident, identified as R24, reaching into the kitchenette's ice machine with bare hands, which is against the facility's infection control practices. This incident was corroborated by a group interview and direct observation by surveyors. The unit manager confirmed that the resident should not have been accessing the ice bin in such a manner, indicating a lapse in monitoring and enforcing infection control protocols within the facility.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for several residents, as evidenced by interviews and record reviews. Residents R31, R39, R10, R40, R2, R6, R50, and R59 voiced concerns about a wandering resident, R24, who frequently entered their rooms uninvited and took personal belongings. Despite these grievances being reported to staff, there was no follow-up or documentation of the incidents, and the facility's grievance process was not followed. Staff members, including CNAs and LPNs, were aware of these concerns but did not report them to the Grievance Official or management. The facility's policy on grievance handling, revised in 2017, mandates that grievances be promptly addressed and resolved to the satisfaction of the resident. However, the policy was not adhered to, as evidenced by the lack of documentation and follow-up on the grievances reported by the residents. The residents expressed their concerns during a Resident Council Meeting and individual interviews, highlighting the facility's failure to address the issues raised. The Director of Nursing refused to be interviewed, and the Nursing Home Administrator acknowledged that staff should follow the grievance process but did not ensure compliance. Specific examples include R31 and R10 reporting that R24 entered their rooms and took belongings, with no action taken by staff. R2 was visibly upset and reported feeling unsafe due to R24's behavior, yet her concerns were not addressed. R59 also reported similar issues with another resident, R56, and was told by a staff member to "just put up with it." These incidents demonstrate a systemic failure in the facility's grievance handling process, resulting in unresolved grievances and a lack of accountability among staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were stored and labeled according to standard practices, leading to the administration of expired medications to residents. During a medication pass, a surveyor observed a registered nurse administering expired Betaxolol eye drops to a resident diagnosed with primary open-angle glaucoma. The nurse acknowledged the medication was expired and should not have been administered. This incident highlights a lapse in the facility's adherence to its policy, which requires checking expiration dates before administering medications. Additionally, the surveyor found expired acetaminophen tablets in the medication cart on the 300 wing, which had been administered to two residents for chronic pain. The registered nurse responsible for administering the medication confirmed that the expired acetaminophen was given to the residents and recognized it as a medication error. The nurse contacted the provider and informed the residents about the error, noting that no adverse effects were observed. The surveyor also discovered an opened multidose vial of Tubersol in the medication room refrigerator with an unreadable date, making it impossible to determine if it was expired. The Director of Nursing acknowledged the issue and the inability to verify the expiration date. The facility's policy requires staff to check medication expiration dates regularly, but the surveyor's findings indicate a failure to consistently follow this protocol, resulting in the administration of expired medications.
Failure to Honor Resident's Choices in Meal and Environment
Penalty
Summary
The facility failed to honor a resident's choices regarding meal substitutions and maintaining a tidy environment, impacting the resident's quality of life. The resident, who is moderately cognitively impaired and requires assistance with activities of daily living, expressed dissatisfaction with the staff's inconsistency in making her bed. Despite her requests, the bed was often left unmade, which was particularly distressing for her when she had visitors. The resident values her personal belongings and a tidy environment, but staff did not consistently respect these preferences. Additionally, the resident's meal preferences were not honored. During a meal, the resident requested a substitution for a blueberry muffin, which was removed from her tray without a replacement being provided. Despite the facility's policy allowing for meal substitutions, the staff failed to offer an alternative in a timely manner. The resident waited 40 minutes for a replacement, which was only provided after the surveyor's intervention. This incident highlights the staff's failure to respect and fulfill the resident's meal choices, affecting her nutritional intake.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically appropriate to self-administer medications. The resident, identified as R30, was observed with medications on the floor and an empty medication cup on the bedside table. The facility's policy requires that residents may only self-administer medications if deemed appropriate by the attending physician and interdisciplinary care planning team. However, R30 did not have a physician's order to self-administer medications, and the facility's assessment did not evaluate R30's ability to take oral medications safely. Despite this, medications were left in R30's room by an LPN, who did not verify if R30 had a self-administration order. Interviews with the LPN, Unit Manager, and Director of Nursing revealed that the medications should not have been left in R30's room without a physician's order. The LPN admitted to leaving the medications in the room and not checking back on R30, who reported taking the pills after picking them up from the floor. Both the Unit Manager and Director of Nursing confirmed that leaving medications in the room and allowing a resident to take medications off the floor was not safe practice. The incident highlights a failure to adhere to the facility's policies and procedures regarding medication administration and resident safety.
Inadequate Sleep Assessment for Hypnotic Medication Use
Penalty
Summary
The facility failed to ensure adequate indications for the use of a high-risk medication, Lemborexant, prescribed to a resident for insomnia. The resident, who has a history of hemiplegia, type 2 diabetes, bipolar disorder, visual hallucinations, major depressive disorder, generalized anxiety disorder, and insomnia, was admitted with a cognitive status indicating they were intact. Despite previous assessments indicating sleep issues, the facility did not conduct a comprehensive sleep assessment before prescribing the hypnotic medication. The facility's policy requires a comprehensive review of the resident's signs and symptoms to identify underlying causes before prescribing psychotropic medications, which was not adhered to in this case. The resident's care plan lacked specific interventions for sleep monitoring and non-pharmacological approaches, and there was no documentation of sleep tracking in the Medication Administration Record or Treatment Administration Record. The facility provided a general monthly evaluation document with minimal sleep assessment, which was insufficient to justify the use of the hypnotic medication. The Director of Nursing was unavailable for an interview regarding this concern, and the facility did not provide any additional sleep-specific assessments when requested by the surveyor.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R40, was offered the pneumococcal vaccine in accordance with CDC recommendations. The facility's policy requires that residents be assessed for eligibility to receive the pneumococcal vaccine series upon admission and that they be offered the vaccine unless medically contraindicated or previously vaccinated. However, R40, who had a documented history of receiving pneumococcal vaccines, was not offered the PCV20 vaccine as recommended. There was no documentation of a declination or consent for the pneumococcal vaccine in R40's medical record. The deficiency was identified during a survey when it was found that the facility did not provide education to the resident or the resident's representative regarding the benefits and potential side effects of the pneumococcal vaccine. Additionally, the facility failed to document whether the resident received the vaccine or refused it. The infection preventionist confirmed that R40 should have been offered the PCV20 vaccine, but this did not occur, resulting in incomplete pneumococcal vaccinations for the resident.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
