Plymouth Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Plymouth, Wisconsin.
- Location
- 916 E Clifford St, Plymouth, Wisconsin 53073
- CMS Provider Number
- 525685
- Inspections on file
- 26
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Plymouth Health Services during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and swallowing difficulties were not served mechanically altered diets as ordered by their physicians. Instead of receiving soft, bite-sized foods, they were given hard, large pieces of pork loin and firm broccoli, contrary to their diet orders and care plans. Staff interviews revealed equipment issues and confusion about food preparation, and both the DON and RD confirmed the meals did not meet prescribed requirements.
A resident with multiple diagnoses, including diabetes and necrotizing fasciitis, did not receive the prescribed Clotrimazole cream due to unavailability. Instead, the facility used a house stock antifungal cream without a physician's order or notification. The MAR showed inconsistent entries, and the DON confirmed the lack of physician notification, violating the facility's Medication Reconciliation policy.
A resident with chronic kidney disease and urinary retention was observed with their catheter drainage bag uncovered and in contact with the floor, contrary to the facility's policy. The resident, who relied on staff for catheter care, was at increased risk of infection due to improper management of the catheter tubing and drainage bag. The Assistant Director of Nursing confirmed the failure to adhere to the facility's catheter care process.
The facility failed to provide consistent hydration for three residents, leading to concerns about inadequate water provision. Residents reported having to request water, with some not receiving it despite asking. Staff interviews revealed that water passes were not consistently completed due to staffing issues, affecting residents' hydration.
A resident in a LTC facility did not receive medications timely as per physician orders. The facility's liberalized medication pass times led to delays in administering medications, including insulin, which was supposed to be given with meals. The resident, who had intact cognition, reported receiving medications late, and the facility's records confirmed these delays.
A resident with moderate cognitive impairment and a history of wandering and disrobing was inadequately supervised after increased supervision was discontinued. The resident's care plan included a motion sensor for monitoring, but staff were unaware of its purpose or did not respond to it. Multiple instances of the resident being found naked outside their room were reported, indicating a lack of effective supervision.
The facility failed to maintain food safety and sanitation standards, affecting all 26 residents. Staff did not perform proper hand hygiene, and a staff member did not wear a beard net while plating food. The handwashing sink was unclean and used for non-handwashing purposes. Kitchen equipment and food items were improperly stored, with unlabeled and expired items found in refrigerators.
A facility failed to maintain necessary court-ordered documents for a resident with severe cognitive impairment, including permanent guardianship and protective placement. The resident's medical record lacked specific details required by state statutes, and the facility could not provide documentation for an annual review or protective placement filing upon admission.
The facility failed to provide required transfer notices to three residents who were hospitalized, and did not notify the State Long-Term Care Ombudsman for two of these cases. Despite the facility's policy, residents and their representatives did not receive written notices, and the Ombudsman was not informed. Interviews with staff revealed inconsistencies in following procedures, leading to these deficiencies.
The facility failed to provide bed hold notifications to three residents during hospital transfers, as required by policy. Despite the policy mandating notification at the time of transfer or within 24 hours, interviews revealed that neither the Nursing Home Administrator nor the Social Service Director ensured compliance. This resulted in residents with varying cognitive abilities not receiving the necessary notifications during their hospitalizations.
A facility failed to notify the state mental health authority after a resident with a diagnosed mental illness experienced a significant change in condition, including an acute psychiatric hospital stay. The resident's PASRR Level I indicated the need for a Level II Screen, which was not completed. The Social Service Director and Nursing Home Administrator confirmed the oversight.
A facility failed to monitor adverse reactions or side effects of high-risk medications for a resident with epilepsy and severely impaired cognition. The resident was prescribed anti-convulsant medications but lacked a care plan addressing seizures or monitoring interventions. The Nursing Home Administrator confirmed the absence of necessary monitoring interventions.
The facility failed to meet the dietary needs and preferences of two residents. One resident, with intact cognition, did not receive their meal preferences due to lost meal tickets, while another legally blind resident did not receive necessary assistance with food placement explanation. The Dietary Manager acknowledged issues with meal ticket management, and the meal ticket for the blind resident lacked necessary instructions, indicating a communication gap.
A facility failed to maintain an effective infection control program when a CNA did not change gloves during care for a resident with a history of neurogenic bladder, UTIs, and diabetes. Despite the facility's hand hygiene policy, the CNA used the same gloves throughout the care process, touching various surfaces and the resident's body, before finally removing the gloves and washing hands. The CNA acknowledged receiving hand hygiene education but forgot to apply it during the care.
A resident with type 2 diabetes did not receive a scheduled insulin dose and received another dose late, contrary to the facility's Medication Administration policy. The resident, with intact cognition, reported these issues, which were confirmed by the Medication Administration Audit Report and the facility's VPS.
Failure to Provide Mechanically Altered Diets as Ordered
Penalty
Summary
Two residents with severe cognitive impairment and a history of swallowing difficulties were not provided with mechanically altered diets as ordered by their physicians. Both residents had physician orders and care plans specifying an L3/Advanced texture diet, which requires foods to be soft, moist, and cut into bite-sized pieces less than one inch. During meal service, both residents received cubed pork loin that was hard and larger than one inch, as well as firm broccoli spears, instead of the required ground meat and soft, mashed broccoli. Tray cards for both residents indicated the correct diet, but the meals served did not comply with these orders. Staff interviews revealed that the blender used to prepare mechanically altered foods was broken, and there was confusion among dietary staff regarding the use of available kitchen equipment. The Dietary Manager confirmed that the food served did not meet the required texture and size, and the Director of Nursing acknowledged that the diet cards should have been followed, especially given the residents' severe dementia and eating difficulties. The Registered Dietitian also confirmed the requirements for the L3/Advanced diet. These failures resulted in the residents not receiving the prescribed diet texture and consistency.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to provide care in accordance with a physician's order for a resident who was admitted with multiple diagnoses, including diabetes, morbid obesity, anxiety, Fournier's disease, and necrotizing fasciitis. The resident had a physician order for Clotrimazole External Cream 1% to be applied twice daily to the right inner thigh for erythema. However, the facility did not administer the prescribed treatment consistently due to the medication being unavailable. Instead, the facility used a house stock antifungal cream, DermaFungal Antifungal Cream 2% Miconazole Nitrate, without obtaining a physician's order or notifying the physician of the change. The Medication Administration Record (MAR) for the resident showed multiple entries indicating the unavailability of the prescribed medication and the use of an alternative cream without proper documentation or physician notification. The Director of Nursing confirmed that the staff did not update the physician or the MAR with the change in medication, which was against the facility's Medication Reconciliation policy. This policy requires that any new orders be transcribed accurately and verified by a second nurse, and that any changes in medication be communicated to the physician.
Inadequate Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care to a resident, leading to an increased risk of urinary tract infections. The resident, who had a history of type 2 diabetes with chronic kidney disease, urinary retention, and benign prostatic hyperplasia, was observed multiple times with their catheter drainage bag uncovered and in contact with the floor. Despite the facility's policy requiring catheter bags to be covered and kept off the floor, the resident's catheter tubing and drainage bag were improperly managed, compromising infection control measures. The resident, who had moderately impaired cognition, relied on nursing staff for catheter care. However, the staff did not adhere to the facility's catheter care policy, as confirmed by the Assistant Director of Nursing (ADON). The ADON was initially unsure of the policy regarding covering catheter bags but acknowledged that the catheter bags and tubing should not be on the floor. The failure to follow the facility's catheter care process was confirmed during an interview with the ADON, highlighting a deficiency in the care provided to the resident.
Inadequate Hydration for Residents
Penalty
Summary
The facility failed to ensure adequate hydration for three residents, R1, R2, and R5, as observed by surveyors. R1, who had intact cognition, reported that the water cup on their bedside table was from two days ago and that water was not provided unless requested. Despite raising this issue in care conferences, R1 continued to experience inadequate water provision. R2, also with intact cognition, stated that they had to ask for water, and the water cup on their bedside table was from the previous night. R5, with moderately impaired cognition, reported that their water cup, containing less than 100 cc of water, was from the previous day, and they had not received water despite requesting it that morning. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were expected to complete water passes each shift, but this was not consistently done due to staffing issues. CNA-F admitted to often not having enough time to complete water passes, while CNA-D confirmed that water passes were sometimes missed due to staffing constraints. Residents who could not ask for water were only provided with fluids during meals and medication administration, indicating a systemic issue in ensuring consistent hydration for all residents.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure the timely administration of medications for a resident, identified as R1, who was part of a sample of five residents. R1, who had intact cognition and was responsible for their healthcare decisions, reported receiving scheduled medications late. The facility's Medication Administration policy required medications to be administered within 60 minutes of the scheduled time, except for those tied to meal times. However, the facility had liberalized medication pass times, which contributed to the delay in medication administration. R1's medical record indicated several physician orders, including medications for diabetes, anxiety, and nerve pain, as well as blood glucose monitoring and insulin administration. The surveyor's review of R1's Medication Administration Record (MAR) and Medication Admin Audit Report revealed multiple instances where medications were administered late. For example, insulin lispro, which was to be given with meals, was often administered well after the scheduled meal times, and blood sugar levels were not obtained as ordered before meals. Interviews with the facility's Vice President of Success (VPS-E) and the Nursing Home Administrator (NHA-A) confirmed the discrepancies in medication administration times. VPS-E acknowledged that R1's insulin should have been administered with meals as ordered and verified that the medications were indeed given late. The facility's meal times did not align with the liberalized medication pass times, leading to the late administration of medications, which was not in accordance with the physician's orders or the facility's policy.
Inadequate Supervision and Monitoring of Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide adequate supervision for a resident with moderate cognitive impairment, who had a history of wandering and disrobing in public. After an allegation of sexual assault, increased supervision for the resident was discontinued, and the facility did not ensure that the resident was adequately monitored to prevent wandering and disrobing incidents. The resident's care plan included interventions such as frequent checks, encouraging activities outside the room, and using a motion sensor to monitor wandering. However, the motion sensor was not effectively monitored, as staff were unaware of its purpose or did not respond to it. Multiple staff members, including CNAs and LPNs, reported instances where the resident was found naked outside their room, indicating a lack of supervision. The motion sensor, intended to assist in monitoring the resident, was not consistently used or understood by all staff, particularly agency staff. Interviews with staff and other residents confirmed that the resident had been seen naked on several occasions, and the facility administration was not aware of these incidents. The lack of formal education on the use of the motion sensor contributed to the deficiency in supervision.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, which had the potential to affect all 26 residents residing in the facility. Staff members did not perform proper hand hygiene before donning gloves, while passing silverware, before touching ready-to-eat food, and while doing dishes. Additionally, a staff member did not wear a beard net while plating food. These actions were observed during meal service, where staff members were seen touching the tips of knives with bare hands and failing to wash hands before donning gloves or after handling soiled equipment. The handwashing sink in the nourishment room on a resident unit was not maintained in a clean condition and appeared to be used for purposes other than handwashing. The sink area contained a sponge with brown edges, a dry, crusted rag, and chunks of food in the drain. The cabinet underneath the sink was in poor condition, with crumbling fiberboard and dark areas that appeared to be mold or mildew. The sink did not have signage indicating it was for handwashing, and the Dietary Manager was unaware of the condition of the cabinet. Kitchen equipment, refrigerators, an ice machine, and dishes were not stored clean, in a down-facing position, covered appropriately, or stored six inches off the floor. Unlabeled and undated food items, as well as expired items, were found in unit refrigerators. The dining room refrigerator contained unlabeled fruit plates and resident meals, while the nourishment room refrigerator had expired cottage cheese and prune juice containers without expiration dates. The Dietary Manager confirmed that food items should be labeled and disposed of when expired.
Failure to Maintain Guardianship and Protective Placement Documentation
Penalty
Summary
The facility failed to ensure that court-ordered documents for guardianship and protective placement were obtained and maintained for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including cerebral palsy and mild cognitive impairment, had a court-appointed guardian. However, the facility did not have the necessary court documents on file to confirm the determination of permanent guardianship or the completion of a court-ordered protective placement, as required by Wisconsin State Statutes. During the survey, it was found that the resident's medical record contained a court document indicating a standby guardian and the need for protective placement, but it lacked specific details such as the name of the facility, the date of protective placement, or the last review date. The Social Services Director and Nursing Home Administrator confirmed the absence of documentation for an annual review of protective placement and permanent guardianship. The facility was unable to provide additional documentation to show that protective placement was filed when the resident was admitted.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide timely and adequate transfer notices to three residents who were hospitalized, as required by their own policy and regulatory standards. Resident 7, who had moderate cognitive impairment, was transferred to the hospital following a fall with injury but did not receive a written transfer notice. Additionally, the State Long-Term Care Ombudsman was not informed of this transfer. Resident 12, with intact cognition, was transferred to the hospital on three separate occasions for various medical reasons, including a possible stroke and pre-planned medical testing, yet did not receive written transfer notices for any of these events. Resident 23, who also had intact cognition, was transferred to the hospital with stroke-like symptoms but did not receive a written transfer notice. Furthermore, the Ombudsman was not notified of this transfer either. The facility's policy mandates that in the event of emergency transfers, a Transfer Form should be completed and provided to the resident or their representative, and the Ombudsman should be notified via a monthly list. However, these procedures were not followed for the residents in question. Interviews with facility staff, including the Nursing Home Administrator and the Social Service Director, revealed that the responsibility for issuing transfer notices was not consistently upheld. The Nursing Home Administrator confirmed that transfer notices were not completed, and the Social Service Director acknowledged that they had not been submitting the required monthly notifications to the Ombudsman. This lack of adherence to policy resulted in the failure to properly notify residents and their representatives of transfers, as well as the failure to inform the Ombudsman of such events.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notifications to three residents during their transfers to the hospital, as required by their policy. Resident 7, who had moderately impaired cognition, was transferred to the hospital following a fall with injury and was not given a bed hold notification. Resident 12, with intact cognition, was transferred to the hospital on three separate occasions for various medical reasons, including a possible stroke and pre-planned medical testing, but did not receive any bed hold notifications. Resident 23, also with intact cognition, was transferred to the hospital with stroke-like symptoms and similarly did not receive a bed hold notification. The facility's policy mandates that a bed hold notice should be provided to the resident or their representative at the time of transfer or within 24 hours. However, interviews with the Nursing Home Administrator and the Social Service Director revealed that the process was not followed. The Nursing Home Administrator confirmed that bed hold notices were not provided and stated that nurses should provide at least a verbal notice during emergent transfers. The Social Service Director acknowledged the responsibility to provide bed hold notices but admitted to not completing them, indicating a lapse in the facility's adherence to its own policy.
Failure to Notify State Mental Health Authority After Resident's Significant Change
Penalty
Summary
The facility failed to ensure the state mental health authority was promptly notified following a significant change in mental illness for a resident, identified as R12, who was part of a sample of six residents. R12 was admitted to the facility with a diagnosed mental illness and corresponding medication. Despite R12's acute psychiatric hospital stay from October 25, 2023, through October 30, 2023, the facility did not submit R12's Preadmission Screen and Resident Review (PASRR) Level I for a Level II Screen, which is required following such significant changes in condition. R12's medical record indicated a serious mental illness with symptoms necessitating a Level II Screen, which was not completed. The resident had been admitted to a psychiatric hospital for acute inpatient behavioral health due to suicidal threats and returned to the facility with medication changes. During an interview, the Social Service Director and Nursing Home Administrator confirmed that a PASRR Level II Screen was not completed for R12, acknowledging that it should have been done following the resident's original admission and after the psychiatric hospital stay.
Failure to Monitor Adverse Reactions for High-Risk Medications
Penalty
Summary
The facility failed to monitor for adverse reactions or side effects of high-risk medications for one resident, identified as R3, who was reviewed for unnecessary medications. R3 was prescribed anti-convulsant medications for seizures but did not have a care plan addressing seizures or monitoring interventions for adverse reactions and side effects of these medications. R3 was admitted with a diagnosis of epilepsy and had a severely impaired cognition, as indicated by a BIMS score of 3 out of 15. The medical record showed prescriptions for Gabapentin, Levetiracetam, and Primidone, but lacked a care plan for seizures or monitoring interventions. The Nursing Home Administrator confirmed the absence of monitoring interventions, acknowledging that they should have been in place.
Failure to Follow Meal Preferences and Dietary Needs
Penalty
Summary
The facility failed to ensure meal preferences and dietary needs were consistently met for two residents, R21 and R8, as observed by surveyors. R21, who has intact cognition and a regular diet order, reported that the facility often lost their meal ticket, which included their meal preferences. During a lunch service, R21 did not receive their documented meal preferences, specifically receiving corn, which they had crossed off due to it upsetting their stomach. The Dietary Manager acknowledged issues with lost meal tickets and confirmed that residents should receive their preferences and ordered diets. R8, who is legally blind and has moderately impaired cognition, did not receive the necessary assistance during meal service. Their care plan required staff to explain the placement of food on their plate, but this intervention was not consistently followed. During an observation, staff did not inform R8 about the food on their plate or its location, which R8 confirmed was important to them to avoid eating items they dislike. The meal ticket for R8 did not indicate their visual impairment or the need for food placement explanation, highlighting a gap in communication between dietary staff and care plans.
Inadequate Infection Control Due to Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper glove use by a Certified Nursing Assistant (CNA) during the provision of care for a resident. The facility's Hand Hygiene Policy, dated November 2, 2022, mandates that all staff perform proper hand hygiene procedures, including changing gloves when necessary, to prevent the spread of infection. However, during an observation on June 26, 2024, a surveyor noted that CNA-I did not change gloves while providing peri and catheter care for a resident, identified as R23. This resident had a history of neurogenic bladder, urinary tract infections, and diabetes, and required extensive assistance with bed mobility, transfers, and hygiene. During the observed care, CNA-I and another CNA, CNA-J, initially washed their hands and donned gloves. However, CNA-I failed to change gloves after touching various surfaces and items, including the resident's peri area, Foley catheter tubing, and buttocks, as well as multiple surfaces in the resident's bathroom. CNA-I continued to use the same gloves throughout the care process, which included touching the resident's side, clean brief, and bed, before finally removing the gloves and washing hands. CNA-I later confirmed in an interview that they did not change gloves during the care and acknowledged having received hand hygiene education at the facility but forgot to apply it during the care for R23.
Failure in Timely Insulin Administration
Penalty
Summary
The facility failed to provide routine pharmaceutical services for a resident, specifically in the administration of insulin lispro, a fast-acting medication used to manage blood sugar levels. The resident, who was diagnosed with type 2 diabetes among other conditions, did not receive a scheduled dose of insulin on one occasion and received another dose outside the prescribed time frame. The facility's Medication Administration policy requires medications to be administered at specific times relative to meals and bedtime, but this protocol was not followed in the case of the resident. The resident, whose cognition was fully intact, reported not receiving the 6:00 PM insulin dose on one day and receiving the 10:00 AM dose late on the following day. The Medication Administration Audit Report confirmed these discrepancies, showing no record of the 6:00 PM dose being administered and the 10:00 AM dose being given at 3:43 PM. The facility's Vice President of Success verified the lack of documentation for the missed dose and the late administration of the other dose, confirming the surveyor's findings.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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