Resolve At West Allis Respiratory And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in West Allis, Wisconsin.
- Location
- 9047 W Greenfield Ave, West Allis, Wisconsin 53214
- CMS Provider Number
- 525108
- Inspections on file
- 44
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Resolve At West Allis Respiratory And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required written transfer/discharge notices and complete bed-hold documentation for three hospitalized residents. For a cognitively intact resident with quadriplegia and other conditions, transfer notices were signed only by staff, not acknowledged by the resident or representative, and there was no evidence they were provided in writing in a language understood; associated bed-hold forms lacked a checked reason for the hold and omitted the per diem rate. For another resident with acute respiratory failure, tracheostomy, and cognitive deficits who had a guardian, multiple hospitalizations showed transfer notices without the guardian’s written acknowledgment, bed-hold forms where LPNs—not the guardian—consented to hold the bed, and no documented daily rate. A third ventilator-dependent resident with a legal guardian had bed-hold forms signed by an LPN on the representative line, no guardian signatures on transfer notices, and no per diem rate recorded. The NHA confirmed that only verbal consent is obtained, no written copies are sent to representatives, and that daily bed-hold rates are not documented on the bed-hold notices.
Surveyors identified that the facility’s medication error rate exceeded 5% due to two eye drop administration errors among 31 opportunities. In one case, an LPN administered Prednisolone Acetate 1% eye drops to a resident without properly shaking the bottle, despite a “shake well” label. In another case, a CMA administered Cromolyn Sodium 4% eye drops to a resident by instilling two drops into each eye consecutively without waiting the required interval between drops, contrary to the DON’s stated standard of one minute between drops of the same ophthalmic medication.
A resident admitted with a surgically treated femur fracture had an order for acetaminophen 1000 mg PO q6h for pain that was entered incorrectly in the electronic system as a pharmacy-type order instead of a standard medication MAR order, so it never appeared on the MAR. Over several months, staff reviewed and used the MAR for medication administration, and an LPN confirmed only eye drops and insulin were being given, resulting in 589 missed doses of acetaminophen despite ongoing documentation from an APNP and an orthopedic clinic that the resident should continue this regimen. The nurse manager later identified the incorrect order type as the reason nurses could not see the medication, and the DON reported that no pharmacy recommendation had been received to correct the issue.
A resident with a tracheostomy, gastrostomy tube, and indwelling catheter, on EBP and NPO with continuous tube feeding, received ET medications from an LPN who did not follow infection control policies. The LPN removed the resident’s graduated cylinder and syringe from the room, placed the cylinder on the medication cart leaving fluid on the cart, and did not sanitize the cart before preparing medications for other residents. While wearing contaminated PPE, the LPN exited the EBP room, accessed a shared spoon container on the medication cart, and returned to care for the resident without removing PPE or performing hand hygiene. The LPN repeatedly wiped the syringe, including the tip that connects to the ET, with contaminated gloves after fluid overflow. The ADON and DON confirmed these actions were inconsistent with facility policies requiring resident-specific items to remain in the room, PPE removal and hand hygiene before accessing the cart, and protection of the syringe tip from contamination, resulting in a cited infection control deficiency.
A resident with multiple medical conditions was left alone with physician-ordered medications by an LPN who was unaware of the resident's approval status for self-administration. The DON confirmed that the resident had not been approved for self-administration, and facility policy requires staff to observe medication consumption and ensure only approved residents self-administer medications. This resulted in a failure to follow required procedures for medication administration.
Two residents did not receive their scheduled medications within the required time frames, with multiple instances of late administration documented for pain and muscle spasm medications. Despite facility policy requiring medications to be given within one hour of scheduled times, audit reports showed delays ranging from 42 minutes to over three hours, impacting the effectiveness of prescribed pharmaceutical services.
A nurse failed to prime a new insulin pen before administering insulin to a resident with diabetes, contrary to facility policy and standard practice. Additionally, insulin doses for the same resident were repeatedly administered several hours late on multiple occasions, despite staff being educated on proper medication timing.
Two residents with stage three pressure ulcers were observed receiving wound care in which the Wound Care Nurse did not consistently remove dirty gloves, sanitize hands, or use clean gloves at appropriate times. The nurse also failed to sanitize the overbed table and scissors before use, and did not open dressing supplies prior to care, resulting in lapses in infection control practices.
A resident with a history of pressure injuries and total care needs developed a pressure ulcer on the left ear that was not comprehensively assessed or promptly reported to a provider. Staff did not consistently follow wound care recommendations for daily treatment, instead providing care only three times a week, even as the wound worsened. The care plan intervention to use a neck pillow for offloading was not implemented, as the resident was repeatedly observed without it and staff were unaware of the intervention. These failures resulted in delayed and inadequate pressure ulcer care.
A resident with a facility-acquired sacral pressure injury was observed receiving wound care by an LPN who wore gloves but failed to don a disposable gown, despite CDC signage requiring both gloves and gowns for high-contact care activities under Enhanced Barrier Precautions. The LPN performed proper hand hygiene, but the omission of the gown was acknowledged by both the NHA and DON as not meeting infection control requirements.
A resident's family member was not provided a timely refund after making private payments while a Medicaid application was pending, despite facility policy requiring refunds for retroactive Medicaid coverage. Staff interviews revealed confusion and lack of awareness regarding the refund process and status.
A resident's care plan did not accurately reflect their current DNR code status, despite updated physician orders and documentation in the EMR. The resident was moderately cognitively impaired and unable to make decisions, with a family member as the activated decision maker. Staff interviews confirmed the care plan was not updated to match the resident's actual code status.
Staff failed to follow infection control protocols during wound care and respiratory treatment for two residents under Enhanced Barrier Precautions. An ADON did not perform hand hygiene between glove changes while providing wound care to a resident with a stage 3 pressure ulcer, and a respiratory therapist did not wear a gown while administering a nebulizer treatment to a resident with a tracheostomy. Both actions were inconsistent with facility policy and CDC guidance.
A resident with multiple complex medical conditions was transferred to the hospital without notification to their family representative and activated POA, as required by facility policy. Review of records and staff interview confirmed the lack of notification following the transfer.
Two residents experienced staff-to-resident abuse, including verbal/emotional abuse by an RN and physical abuse by a CNA. In one case, a cognitively intact resident with quadriplegia reported emotional distress after overhearing an RN refuse to care for him. In another, a resident with diabetes and COPD was physically struck by a CNA during care, as witnessed by another staff member. Both abuse allegations were substantiated by facility investigations.
A resident with diabetes and COPD, who was cognitively intact, was involved in an incident where a CNA allegedly used physical force and vulgar language. The event was not reported to administration until 14 hours after it occurred, due to staff assuming another manager had already reported it. This delay was contrary to facility policy requiring immediate reporting of suspected abuse.
A resident with quadriplegia and orthostatic hypotension received Midodrine despite physician orders to hold the medication if systolic blood pressure was above 110. Documentation showed the medication was administered multiple times outside the ordered parameters, and both the resident and DON confirmed these errors occurred.
A resident with End Stage Renal Disease did not have their AV fistula monitored for bruit and thrill as required. The facility's policy and professional guidelines were not followed, and there was no active order for monitoring from the end of the last survey until the current survey began. Staff interviews revealed inconsistencies in understanding the monitoring requirements. The issue was identified during an audit, but corrective actions were not implemented until after the survey started.
A resident with a Stage 4 pressure injury did not receive incontinence care before a dressing change, potentially contaminating the wound with fecal matter. The LPN and ADON failed to clean the resident's skin, leaving the resident on a soiled pad. Despite the LPN's claim of no visible feces on the dressing, the surveyor noted the risk of contamination due to the proximity of stool to the wound.
A resident with multiple health issues, including muscle weakness and chronic kidney disease, expressed a desire to return home but lacked an effective discharge plan. The facility failed to identify specific barriers, education needs, and necessary equipment or home services for a successful discharge. Staff communication and documentation were inadequate, leading to an ineffective discharge planning process that did not focus on the resident's goals and safety.
A resident with hemiplegia and cognitive deficits did not receive requested grooming services, such as nail trimming and face shaving, due to the facility's reliance on the resident's refusal of showers as a reason. Despite the resident's care plan indicating the need for assistance with ADLs, the facility did not provide these services, leading to a deficiency noted by surveyors.
A resident with quadriplegia and anxiety was unable to email grievances due to a facility policy change, which was not effectively communicated. The facility's grievance process lacked clarity and did not provide written decisions as required. Staff inconsistencies and failure to accommodate the resident's physical limitations led to a deficiency in honoring the resident's rights.
A facility failed to report an incident of alleged verbal abuse and possible neglect involving a resident to the Nursing Home Administrator and State agency within the required timeframe. The incident, witnessed by a Med Tech, involved a staff member yelling at a resident and refusing to change him while he was soiled. The delay in reporting this incident constitutes a deficiency in the facility's adherence to its policy on reporting abuse and neglect.
A resident with severe cognitive impairment did not receive prescribed doses of Tramadol and Lorazepam due to a medication administration failure. The RN Supervisor removed medication cards from an unlocked cart, resulting in missed doses. The Med Tech documented the medications as unavailable and reported the issue, which was later resolved by the RN Supervisor returning the medications.
The facility's Water Management Plan was outdated and failed to identify and control Legionella risks, with inadequate monitoring and inconsistent documentation. The plan did not reflect current standards or team members, and the Director of Maintenance was unaware of the plan, indicating a lack of training and implementation. These deficiencies posed a risk of Legionella growth and spread within the facility.
A resident with limited range of motion was observed multiple times without the prescribed palm protectors, despite the care plan indicating they should be applied daily. The resident, with a history of several medical conditions, reported not knowing where the splints were. Facility documentation indicated the protectors were applied, but there was no documentation of refusal, highlighting a deficiency in adherence to the care plan and documentation practices.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45% during a medication pass. An LPN crushed medications for a resident, including Cinacalcet and Pantoprazole, which were contraindicated for crushing. Despite a physician's order allowing for medications to be crushed unless contraindicated, the LPN proceeded with the error. The issue was acknowledged by the LPN and reported to the ADON, but no further information was provided.
The facility did not ensure insulin vials for two residents were labeled with expiration dates as per professional standards. Insulin for two residents was opened and used without being dated, contrary to facility policy and guidelines. Staff were unable to provide additional information or ensure compliance during the survey.
The facility failed to report an allegation of exploitation involving a resident and an LPN to the State Survey Agency. The resident reported buying gifts for the LPN, but the DON did not believe the allegation was valid due to the resident's mental state and did not report it. The facility's grievance log did not show any grievance filed by the resident regarding this issue.
The facility failed to investigate allegations of a resident buying gifts for an LPN, despite the resident reporting the issue and calling the police. The DON and NHA were aware of the situation but did not conduct a thorough investigation as required by the facility's policy.
Failure to Provide Written Transfer Notices and Complete Bed-Hold Documentation for Hospitalized Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notices and complete bed-hold documentation, including the per diem rate, for three residents during hospitalizations. Facility policy titled “Bed Hold Notice” (revised 8/2025) requires that residents and/or their representatives receive written information about bed-hold practices both at admission and at the time of transfer for hospitalization or therapeutic leave, including the duration of any state bed-hold policy, reserve bed payment policy, facility bed-hold policies, and conditions for return. The policy also requires written notice of bed-hold policies within 24 hours of an emergency transfer, documentation of attempts to reach representatives, and retention of a signed and dated copy of the bed-hold notice in the resident’s record. Interviews with the Nursing Home Administrator (NHA) confirmed that the facility only obtains verbal acknowledgement for transfer/discharge and bed-hold notices and does not provide written copies to representatives, and that the per diem rate varies by level of care. For one resident with quadriplegia, epilepsy, dysphagia, insomnia, anxiety disorder, and major depressive disorder, who was cognitively intact per a BIMS score of 15, the facility completed transfer notices for two hospitalizations. The first transfer notice documented the transfer date, a general reason that the transfer was necessary for the resident’s welfare, and specified “Sent out for NP (nasal prongs)” as the reason, and included required agency contact information for appeals. However, the notice was signed only by a facility employee and not acknowledged by the resident or representative, and there was no documentation that the notice was provided in writing in a language understood by the resident or representative. The associated bed-hold notice did not have the reason for the bed hold (hospital admission vs. therapeutic leave) checked and did not include the facility’s basic per diem rate, although it documented that the POA agreed to the bed hold. For the second hospitalization, the transfer notice again was signed only by a facility employee, did not specify the reason for transfer in the “Specify” field, and there was no evidence that the resident or representative received the notice in writing in a language they understood. The corresponding bed-hold notice indicated admission to the hospital and that the representative requested a bed hold and received verbal notice, but again omitted the basic per diem rate. For a second resident with acute respiratory failure with hypoxia, tracheostomy status, and cognitive communication deficit, whose MDS documented short- and long-term memory problems and that the resident was rarely understood and rarely understood others, and who had a guardian, multiple hospitalizations occurred. For each hospitalization, the facility generated a notice of transfer and a bed-hold notice. On one hospitalization, the transfer notice contained a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice showed an LPN consenting to hold the bed without evidence of guardian consent and without a documented daily rate. On a subsequent hospitalization, the same pattern occurred: no guardian signature on the transfer notice, an LPN consenting to the bed hold, and no daily rate on the bed-hold form. For two later hospitalizations, the transfer notices documented that verbal consent was obtained from the guardian, but there was no evidence that written notices were provided to the guardian, and the bed-hold forms again lacked the daily rate. The NHA confirmed that nurses complete these forms, that only verbal consent is obtained, that no written copies are sent to representatives, and that consent to hold a bed should come from the resident or representative, not from facility staff. For a third resident with chronic respiratory failure, ventilator dependence, encephalopathy, dysphagia, tracheostomy status, and traumatic subdural hemorrhage, who had a legal guardian, similar issues were identified. During one hospitalization, the bed-hold notice showed an LPN signing on the resident representative’s signature line to consent to holding the bed, with no evidence of the guardian’s consent and no daily rate documented. During a later hospitalization, the notice of transfer included a signature line for the resident or representative, but there was no guardian signature, and the bed-hold notice again lacked evidence of guardian consent and did not include the daily rate. In interviews, the NHA reiterated that only verbal consent is obtained for transfer and bed-hold notices, that no written copies are sent to representatives, and that the daily bed-hold rate is only listed in admission paperwork, not on the bed-hold notices themselves. Surveyors noted the absence of written notices to representatives, the lack of resident/representative signatures acknowledging receipt, the improper substitution of staff signatures for representative consent on bed holds, and the omission of the per diem rate on all reviewed bed-hold forms for these residents.
Medication Error Rate Above 5% Due to Improper Eye Drop Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 medication errors in 31 opportunities, resulting in a 6.45% error rate. For one resident (R7), a surveyor observed an LPN retrieve Prednisolone Acetate Ophthalmic Solution 1% from a medication cart; the eye drop bag had a blue sticker instructing to “shake well.” The LPN entered the resident’s room, checked the resident’s blood sugar, performed hand hygiene, donned gloves, and then administered one drop of Prednisolone Acetate 1% into the resident’s left eye without shaking the bottle. The surveyor did not observe any shaking of the eye drop bottle prior to administration. When questioned later, the LPN stated she had shaken the drops by tipping the bottle down and back up, and the nurse manager demonstrated that “shake well” should involve moving the hand back and forth quickly multiple times, confirming that the observed technique did not meet the expected standard. In a separate incident involving another resident (R9), a surveyor observed a CMA prepare multiple medications, including Cromolyn Sodium Ophthalmic Solution 4%. After verifying the oral medications, the CMA donned gloves and a gown, entered the resident’s room, and administered the oral medications with water. The CMA then informed the resident about the eye drops, handed the resident a tissue, and instilled two drops of Cromolyn Sodium 4% into the left eye while counting “one, two,” followed immediately by two drops into the right eye in the same manner, without waiting any time between drops in either eye. Later, when the DON was asked about proper eye drop administration, the DON stated that staff should wait one minute between drops of the same eye medication and three to five minutes between different eye medications. The surveyor’s observation that no waiting period occurred between drops for this resident constituted a second medication error.
Failure to Transcribe Acetaminophen Order to MAR Resulting in Multiple Missed Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a standing order for acetaminophen 1000 mg by mouth every six hours for pain/discomfort, with a start date of 8/21/25, was not correctly entered into the electronic system and therefore did not appear on the resident’s MARs. The facility’s medication orders policy requires that each medication order be documented on the physician order sheet and the MAR, and that newly prescribed medications be transcribed or ensured to appear in the electronic MAR. Despite this, the acetaminophen order, which was present under the physician orders tab, was not listed on the resident’s MARs for multiple consecutive months, resulting in the resident missing 48 doses in August, 120 in September, 124 in October, 120 in November, 124 in December, and 53 in January, for a total of 589 missed doses. The resident had been admitted with a left periprosthetic distal femur fracture treated surgically and had ongoing pain management needs, with documentation from an APNP and an orthopedic clinic after-visit summary confirming continued orders for acetaminophen 1000 mg every six hours. Surveyor review of the MARs for August through January confirmed the absence of the acetaminophen order despite its presence in the physician orders. During medication pass observation, the LPN administered only eye drops and insulin to the resident and confirmed there were no other medications to be given at that time. When questioned, the nurse manager/LPN explained the facility’s process for entering new admission medications, including using the hospital after-visit summary and a three-check review system, and confirmed that the physician orders tab reflected current orders. Upon reviewing the resident’s electronic orders, the nurse manager identified that the acetaminophen order type had been incorrectly entered as “pharmacy” instead of “standard medication MAR,” which prevented it from appearing on the MAR and from being visible to nurses during medication administration. The DON reported that the facility also relies on remote pharmacy checks and recommendations but stated that no pharmacy recommendation had been received regarding this resident’s acetaminophen order.
Failure to Follow Infection Control Practices During Enteral Tube Medication Administration Under EBP
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during enteral tube (ET) medication administration for one resident on Enhanced Barrier Precautions (EBP). The resident had acute respiratory failure with hypoxia, a tracheostomy, a gastrostomy tube, an indwelling urinary catheter, was NPO with continuous tube feeding, and was dependent on staff for all ADLs. Facility policies required keeping the medication cart clean and using EBP, including gown and gloves for high-contact care involving devices such as feeding tubes, tracheostomies, and catheters, and disposing of PPE before exiting the room or before providing care to another resident. During a medication pass, an LPN prepared and administered ET medications for this resident and did not consistently follow infection control practices. After initially performing hand hygiene and donning PPE, the LPN brought the resident’s graduated cylinder and syringe, prefilled with water and used for ET care, out of the resident’s room and placed the cylinder on the medication cart, leaving a puddle of fluid of unknown contamination on the cart. The LPN did not sanitize the cart and later placed medication cups and a stethoscope on the same contaminated surface. The LPN also repeatedly wiped the syringe, including the tip that connects directly to the resident’s ET, with a contaminated gloved hand after water or medication mixture dripped down the syringe during flushing and medication administration attempts. While wearing PPE in the EBP room, the LPN exited the room without removing gown and gloves or performing hand hygiene and accessed a shared spoon container on the medication cart used for all residents, then returned to the room and continued care without changing PPE or performing hand hygiene. The LPN used the spoon to mix the medication and continued to manipulate the syringe and ET with the same contaminated gloves. The LPN later discarded the clogged syringe and medication mixture, obtained a new syringe and medication, and repeated similar practices of wiping the syringe, including the tip, with contaminated gloves after fluid overflow. Interviews with the LPN, the ADON (infection preventionist), and the DON confirmed that these actions were not consistent with facility expectations or standard practice, including that resident-specific items such as the graduated cylinder should not leave the room, PPE should be removed and hand hygiene performed before accessing the medication cart or exiting an EBP room, and the syringe tip that connects to the resident should not be wiped with a gloved hand. The facility’s own leadership acknowledged that the observed practices did not align with their policies and expectations. The ADON stated that staff are expected to remove PPE before exiting an EBP room and before accessing anything outside the room, especially a shared medication cart, and that resident-specific care items like the graduated cylinder should not be placed on communal surfaces. The DON similarly stated that the graduated cylinder should remain in the resident’s room, medications should be prepared either at the bedside with that cylinder or at the cart with another water source, and that staff must remove gloves and perform hand hygiene before accessing the cart and then re-perform hand hygiene and don gloves before resuming care. Both the ADON and DON stated there is no standard of practice to wipe a syringe, particularly the tip that connects to the resident, with a contaminated gloved hand. These statements, combined with the surveyor’s observations, establish that the facility did not maintain its infection prevention and control program as required by its own policies and EBP standards during ET medication administration for this resident. The surveyor’s interviews further documented that the LPN acknowledged that bringing the graduated cylinder out of the room and placing it on the cart was not standard practice and that the cylinder should not leave the room. The LPN also acknowledged that it is not standard practice to wipe off a syringe with a contaminated gloved hand prior to administering fluids or medications through an ET and that accessing items on the cart while wearing contaminated PPE is not consistent with infection control standards. Despite these acknowledgments, the observed actions during the medication pass demonstrated multiple breaches of infection control, including contamination of the medication cart, improper handling of resident-specific equipment, failure to remove PPE and perform hand hygiene before accessing shared supplies, and improper handling of the syringe tip used for ET access. These combined actions and inactions led to the cited deficiency in the facility’s infection prevention and control program.
Failure to Assess and Approve Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and approved for self-administration of medications before being left alone with physician-ordered drugs. The resident, who had diagnoses including type two diabetes mellitus, hypertension, and a history of transient ischemic attack, was cognitively intact as indicated by a perfect BIMS score. During a medication pass, an LPN brought the resident's morning medications into the room, placed them on the overbed table, and then left the room, leaving the medications unattended with the resident. The LPN later returned and administered the medications to the resident. Upon inquiry, the LPN was unsure if the resident had been approved for self-administration of medications and confirmed that she could not observe the medications while out of the room. The Director of Nursing confirmed that the resident had not been approved for self-administration. Facility policy requires that only residents approved by the interdisciplinary team may self-administer medications and that staff must observe residents consuming their medications. The failure to follow these procedures resulted in the resident being left unsupervised with medications without proper assessment or approval.
Failure to Ensure Timely Medication Administration
Penalty
Summary
The facility failed to ensure timely administration of medications for two of three residents reviewed for late medications. Record review and interviews revealed that one resident, who was cognitively intact and had diagnoses including quadriplegia and an unhealed stage three pressure ulcer, reported receiving medications either too early or late. The medications involved included Tylenol, Gabapentin, Baclofen, and Tizanidine, all of which were prescribed to be administered four times daily. The resident stated that late administration affected the timing of subsequent doses, causing them to be too close together. Audit reports from the electronic medical record showed multiple instances where medications were administered significantly outside the scheduled times, ranging from 42 minutes to over three hours late. These delays occurred repeatedly over several dates and involved various scheduled doses throughout the day and night. The medications affected were primarily for pain and muscle spasm management, and the late administration was consistently documented in the facility's records. The facility's policy, as reviewed in staff meeting documentation, required medications to be administered within one hour before or after the scheduled time unless otherwise specified by physician orders. Despite this policy, the documented medication administration times for the affected residents did not comply with the required time frames, resulting in a failure to meet the pharmaceutical service needs of the residents as outlined by facility policy and physician orders.
Failure to Prime Insulin Pen and Timely Administer Insulin
Penalty
Summary
A deficiency was identified when a nurse failed to prime a new insulin pen prior to administering insulin to a resident diagnosed with type 2 diabetes mellitus, hypertension, and a history of transient ischemic attack. The nurse admitted to not priming the pen before injection, which is contrary to both facility policy and standard practice, as confirmed by the Director of Nursing. The facility's policy requires insulin pens to be primed before use to ensure the correct dose is delivered and to avoid air in the reservoir. The resident involved was cognitively intact, as indicated by a perfect BIMS score. Additionally, the facility failed to administer insulin as ordered for the same resident on multiple occasions. Medication administration records showed that the resident's scheduled morning insulin doses were given several hours late on at least five separate dates. Interviews with nursing staff and the DON confirmed that staff are educated to administer medications within one hour before or after the scheduled time, but the audit revealed repeated late administrations outside this window.
Failure to Follow Infection Control Guidelines During Wound Care
Penalty
Summary
During wound care observations for two residents with stage three pressure ulcers, the facility failed to adhere to established infection control guidelines. For the first resident, who was cognitively intact and had a pressure ulcer on the left buttock, the Wound Care Nurse (WCN) did not remove dirty gloves, sanitize hands, or don clean gloves at appropriate intervals during the wound care process. Specifically, after assisting with repositioning and before removing the old dressing, the WCN failed to change gloves and sanitize hands. Additionally, the WCN did not sanitize hands between glove changes when handling clean wound care supplies and dressings. For the second resident, who had respiratory failure, anoxic brain injury, and an unhealed stage three pressure ulcer, similar lapses were observed. The WCN did not sanitize the overbed table before placing a clean barrier, failed to sanitize hands between glove changes, and used scissors to cut dressing material without sanitizing them beforehand. The WCN also did not open dressing supply packages prior to performing wound care, as required by infection control protocols. Interviews with the WCN, Infection Preventionist, and Director of Nursing confirmed that the observed practices did not align with facility expectations or infection control standards. The facility's wound treatment management policy did not specify infection control guidelines to be followed during wound care, contributing to the observed deficiencies.
Failure to Provide Timely and Comprehensive Pressure Ulcer Care
Penalty
Summary
A resident with a history of pressure injuries, severe cognitive impairment, and total dependence for care developed a pressure injury on the left ear. The initial discovery of the wound was not followed by a comprehensive assessment, as required by facility policy. Documentation was incomplete, with missing measurements, wound staging, and a lack of timely notification to the medical provider. The wound was first noted on 5/2, but there was no evidence of provider notification or treatment orders until 5/4. Additionally, there was confusion regarding who documented the initial finding, as the nurse listed was not present in the facility at the time. After the wound was identified, the care plan was updated to include the use of a neck pillow to offload pressure from the ear. However, multiple observations by the surveyor found the resident without the neck pillow, and staff interviews revealed a lack of awareness about this intervention. The resident was repeatedly observed with direct pressure on the affected ear, contrary to the care plan. Staff members, including CNAs and LPNs, denied knowledge of the neck pillow intervention, and there was no evidence that the intervention was consistently implemented. Despite recommendations from the wound nurse practitioner and facility wound nurse for daily wound treatments, staff continued to provide care only three times a week for several weeks. This was not in accordance with the recommended frequency, and the wound subsequently worsened, doubling in size. No additional interventions were implemented when the wound deteriorated. Comprehensive wound assessments were not consistently completed, and provider recommendations were not promptly followed. The facility failed to ensure that the resident received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols during the wound care of a resident with a facility-acquired pressure injury to the sacral area. During a surveyor's observation, CDC signage was posted outside the resident's room indicating that Enhanced Barrier Precautions (EBP) were required, including the use of gloves and gowns for high-contact resident care activities such as wound care. Despite these posted requirements, the LPN performing the wound treatment donned gloves but did not wear a disposable gown throughout the procedure. The LPN performed appropriate hand hygiene before, during, and after the wound care, but did not comply with the full PPE requirements as outlined by the CDC and facility signage. During an interview, both the Nursing Home Administrator and Director of Nursing acknowledged awareness that the LPN had not properly donned the required PPE while providing wound care. This failure to use the appropriate PPE during a high-contact procedure constituted a breach of the facility's infection prevention and control program.
Delayed Refund Following Retroactive Medicaid Approval
Penalty
Summary
The facility failed to provide a timely refund to a resident's family member after the resident's Medicaid application for long-term care services was approved retroactively. Documentation showed that the family member had made two private payments totaling $7,853 while the Medicaid application was pending. The facility's admission packet stated that if Medicaid coverage is retroactive for a period for which payment has already been made, the facility would refund or credit any excess amount within thirty days of Medicaid eligibility being established. However, interviews with the Business Office Manager and Accounts Receivable Manager revealed confusion and lack of awareness regarding the status of the refund, with the Accounts Receivable Manager only being alerted to the balance due back to the family member months after Medicaid approval. The resident was initially covered by a Medicare Advantage plan, which later discontinued skilled services, leading to the resident being considered private pay until Medicaid approval. The resident's Social Security check was used for the patient portion of payment, and the family member shared a bank account with the resident, complicating the determination of the funding source. Despite the facility's policy and the retroactive Medicaid coverage, the refund process was delayed, and staff were unclear about the procedures and status of the refund owed to the family member.
Care Plan Failed to Reflect Accurate Code Status
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the resident's current code status. According to the facility's policy, care plans are to be revised as information about residents and their conditions change. The resident was admitted with a care plan indicating full code status, but subsequent documentation in the electronic medical record, including physician orders and the facility dashboard, showed the resident was designated as do not resuscitate (DNR). The Minimum Data Set assessment indicated the resident was moderately cognitively impaired and unable to make decisions for herself, with her family member acting as the activated decision maker. Interviews with the resident's family member and the Social Services Director confirmed that the resident's code status was DNR and that the care plan did not accurately reflect this status. The Social Services Director acknowledged the inaccuracy of the care plan, and the Director of Nursing stated that her expectation was for the care plan to have the correct code status. This discrepancy between the care plan and the resident's current clinical status was identified through interviews, record review, and policy review.
Failure to Follow Infection Control Practices During Wound Care and Respiratory Treatment
Penalty
Summary
The facility failed to adhere to established infection prevention and control practices during wound care and respiratory treatments for residents under Enhanced Barrier Precautions (EBP). During a wound care observation, the Assistant Director of Nursing (ADON) and an LPN performed hand hygiene and donned appropriate PPE before starting the procedure. However, after removing soiled gloves, the ADON failed to perform hand hygiene before donning clean gloves and proceeding with wound cleansing, which was not in accordance with the facility's hand hygiene policy. The ADON later acknowledged the missed hand hygiene step during an interview, and the Director of Nursing (DON) confirmed that hand hygiene is expected between every glove change. A review of the resident's records indicated that the resident receiving wound care had a diagnosis of hemiplegia and a stage 3 pressure ulcer, and was on Enhanced Barrier Precautions due to skin breakdown. The facility's policy and CDC guidance require strict adherence to hand hygiene and PPE use for residents with wounds or indwelling devices to prevent the spread of multidrug-resistant organisms (MDROs). In a separate incident, a respiratory therapist (RT) performed a nebulizer treatment for a resident with a tracheostomy, also under EBP, but failed to don a gown as required. Although the RT performed hand hygiene and wore gloves, the omission of the gown was contrary to both the posted EBP instructions and facility policy. The RT acknowledged the lapse during an interview, and the DON reiterated the expectation for proper PPE use during high-contact care activities for residents under EBP.
Failure to Notify POA of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's family representative and Power of Attorney (POA) of a hospital transfer for one resident. According to the facility's policy, staff are required to inform the resident, their physician, and a family member or representative of any significant events, including hospital transfers. Review of the clinical record for the resident revealed that the individual was transferred to the hospital, but there was no documented evidence that the family representative or POA was notified of this transfer. The resident in question had multiple medical diagnoses, including major depressive disorder, muscle weakness, polyneuropathy, bacteremia, gait abnormalities, diabetes with complications, and partial toe amputations. The resident's Healthcare Power of Attorney had been activated prior to the transfer, indicating that the family member was authorized to make healthcare decisions. During an interview, the Administrator confirmed that the family representative and POA were not notified of the hospital transfer, as required by facility policy.
Failure to Protect Residents from Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident abuse in two separate cases. In the first case, a resident with quadriplegia and full cognitive function reported that a registered nurse made statements to another employee outside his room, indicating a refusal to care for him and delegating his medication administration to another nurse. The resident reported experiencing emotional anguish and feeling unsafe as a result of these statements. The incident was reported to the facility's administrator, and the facility's investigation substantiated the allegation of verbal/emotional abuse. In the second case, a resident with type 2 diabetes and COPD, who was also cognitively intact, was subjected to physical abuse by a certified nursing assistant. Another staff member witnessed the CNA swat the resident on the hand after the resident accidentally grabbed the CNA's arm during repositioning, and also heard the CNA use vulgar language toward the resident. The facility's investigation substantiated the physical abuse but could not substantiate the verbal abuse. Both incidents were confirmed by the facility's administrator and director of nursing during interviews.
Failure to Timely Report Suspected Abuse Incident
Penalty
Summary
The facility failed to ensure the timely reporting of a potential abuse incident involving a resident with type 2 diabetes and COPD, who was cognitively intact as indicated by a BIMS score of 15. According to the facility's policy, staff are required to immediately report any suspicious event or injury that may constitute abuse, neglect, exploitation, or misappropriation to the Executive Director. However, a staff member witnessed a CNA swat the resident on the hand and use vulgar language during care, but the incident, which occurred at 5:30 AM, was not reported to facility administration until 7:30 PM, resulting in a 14-hour delay. Interviews revealed that the delay occurred because the staff member who witnessed the incident assumed another RN Manager, who was present during the event, had already reported it. The acting RN Manager only became aware of the incident when she started her shift and was informed by another CNA. Upon learning of the incident, the RN Manager immediately notified the Administrator, who confirmed that the alleged abuse had not been previously reported. The Administrator then reported the incident to the State Agency and local law enforcement, but confirmed that the initial reporting to administration was not timely.
Failure to Withhold Medication per Physician Order
Penalty
Summary
A resident with diagnoses of quadriplegia and orthostatic hypotension was admitted to the facility and had a physician's order for Midodrine 10 mg by mouth three times daily, to be held if the resident's systolic blood pressure exceeded 110. The facility's policy required adherence to the five rights of medication administration, including administering medications at the right time and under the correct parameters. Record review revealed that the resident received Midodrine on multiple occasions when his systolic blood pressure was above the ordered threshold, as documented in the Medication Administration Record (MAR). The resident, who was cognitively intact with a BIMS score of 15, confirmed during an interview that he had received the medication outside the prescribed parameters and expressed concern about the potential impact on his health. The DON also confirmed that these medication errors had occurred and acknowledged that medications were not administered as ordered for this resident.
Failure to Monitor Dialysis AV Fistula
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care had their Arterio-Venous (AV) Fistula monitored for bruit and thrill in accordance with professional standards of practice. The resident, who has End Stage Renal Disease among other diagnoses, did not have a medical doctor's order for monitoring the AV fistula for bruit or thrill from the end of the last recertification survey until the start of the current survey. The facility's policy and professional guidelines require regular monitoring of the AV fistula to prevent complications such as clotting or infection. The resident's care plan initially included an intervention to monitor the AV fistula for bruit and thrill, but this was canceled in April 2023. Subsequently, there was no active order or intervention for monitoring the AV fistula until December 2024, after the current survey began. Interviews with facility staff revealed a lack of clarity and consistency regarding the monitoring of the AV fistula, with some staff unsure of the frequency or method of assessment. The Director of Nursing acknowledged that the order for monitoring was not placed as an active order when the resident returned from a hospital admission. The facility identified the issue during an audit conducted over the weekend before the survey started, but the corrective action was not implemented until after the survey began. Documentation from the dialysis clinic indicated that the AV fistula was assessed on dialysis days, but not by the facility staff each shift as required.
Failure to Maintain Sanitary Conditions During Wound Care
Penalty
Summary
The facility failed to maintain a sanitary environment during wound care for a resident with a Stage 4 pressure injury to the coccyx. The resident, who was incontinent of liquid stool, did not receive incontinence care prior to a dressing change performed by an LPN. The LPN proceeded with the dressing change without cleaning the feces from the resident's buttocks and intergluteal cleft, potentially contaminating the wound dressing with fecal matter. The resident, who had a history of sepsis from the coccyx pressure injury, was totally dependent on staff for all care and had multiple medical conditions, including cardiac arrest, dysphagia, chronic respiratory failure, and diabetes. The resident's care plan included interventions for incontinence management and skin protection, but these were not followed during the observed dressing change. The LPN, assisted by the ADON, did not perform the necessary incontinence care before or after the dressing change, and the resident was left lying on a pad covered in liquid feces. The surveyor observed the dressing change and expressed concerns about the potential introduction of fecal bacteria into the wound. Despite the LPN's assertion that no feces were visible on the dressing, the surveyor highlighted the risk of contamination due to the proximity of the stool to the wound. The Nursing Home Administrator acknowledged the situation but noted that the LPN and ADON had other residents requiring wound care, which contributed to the oversight.
Deficient Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R79, had an effective discharge plan that focused on the resident's goals and safety. R79, who was admitted with multiple health issues including muscle weakness, type 2 diabetes, and chronic kidney disease requiring dialysis, expressed a desire to return home. However, the discharge care plan developed for R79 lacked measurable objectives and defined interventions consistent with the resident's needs and goals. The care plan did not identify specific barriers, education needs, equipment, or home services required for a successful discharge. During the survey, it was observed that R79 was experiencing nausea and vomiting, and there was a lack of communication among staff regarding these issues. The certified nursing assistant (CNA) and social worker (SW) involved in R79's care were not adequately informed or involved in the discharge planning process. The SW admitted that the discharge care plan was not updated regularly, and there was a lack of coordination in arranging the necessary durable medical equipment and home care services for R79's discharge. Interviews with the nursing home administrator and other staff revealed that there was a documentation issue, as changes or updates to R79's care plan were not being recorded. This lack of documentation and communication contributed to the ineffective discharge planning process, which did not adequately address R79's discharge goals and safety needs. The facility's failure to develop and implement a comprehensive discharge plan for R79 was identified as a deficiency by the surveyor.
Failure to Provide Necessary Grooming Services to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R50, received necessary grooming services, specifically nail trimming and face shaving, despite the resident's requests. R50, who has diagnoses including hemiplegia, hemiparesis, and cognitive communication deficit, was assessed to be dependent on staff for personal hygiene. The resident's care plan included interventions for nail care as needed and daily assistance with ADLs. However, the facility did not provide these services, citing R50's refusal of showers as the reason, even though nail trimming and shaving do not require a full bath. Observations and interviews revealed that R50 had long fingernails and had not been shaved, despite expressing a desire for these grooming services. The facility's documentation showed that R50 refused showers, but there was no documentation of refusals for nail trimming or shaving. The care plan was revised to include refusals of therapy and showers, but no interventions were implemented for the shower refusals. The facility's failure to address R50's grooming needs, despite the resident's requests and the care plan's directives, led to the deficiency noted by the surveyor.
Deficiency in Grievance Process for Resident with Quadriplegia
Penalty
Summary
The facility failed to ensure that a resident, identified as R4, was able to voice grievances in a manner they preferred, specifically through email, and did not provide written grievance decisions as required. The facility issued a letter to residents stating that grievances could no longer be emailed, citing potential delays in response and non-compliance with state and federal requirements. This decision was not communicated effectively to R4, who was not informed of any changes allowing email grievances. R4, who has quadriplegia and anxiety, expressed that the inability to email grievances was discriminatory and violated his rights, as he could not physically write due to his condition. The facility's grievance process was found lacking in several areas. The grievance log reviewed by the surveyor did not include whether grievances were confirmed or not confirmed, nor did it provide the date written decisions were issued to R4. Additionally, R4 reported that staff members paraphrased his grievances instead of recording them verbatim, and he was not provided with copies of his grievances, which he felt could lead to misinterpretation or downplaying of his concerns. The facility's policy required that written grievance decisions include specific details, but this was not adhered to in R4's case. Interviews with facility staff revealed inconsistencies in the grievance process. The Nursing Home Administrator (NHA) and Assistant NHA provided conflicting information about the acceptance of email grievances and the process for filing them. The Assistant NHA mentioned plans to implement a grievance email address and educate residents on its use, but this had not been completed at the time of the survey. The facility's failure to provide a clear and accessible grievance process, particularly for residents with physical limitations, resulted in a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal.
Delayed Reporting of Alleged Verbal Abuse and Neglect
Penalty
Summary
The facility failed to report an incident of alleged verbal abuse and possible neglect involving a resident, identified as R6, to the Nursing Home Administrator and the State survey agency within the required timeframe. The incident occurred on July 10, 2024, but was not reported until July 16, 2024, six days later. The facility's policy mandates immediate reporting of such allegations to the Executive Director and relevant agencies. The resident involved, R6, has diagnoses including epilepsy, anoxic brain injury, and depression, and was assessed as cognitively intact. The incident involved a staff member allegedly yelling at R6 and refusing to change him, which was witnessed by Med Tech-E, who intervened and reported the incident to an RN Supervisor. Med Tech-E reported hearing a staff member, identified as CNA-J, yelling at R6 and refusing to change him, while R6 was found soiled. Med Tech-E intervened and later reported the incident to RN Supervisor-D, who could not recall the details when questioned by the surveyor. The Director of Nursing later confirmed that the incident was not reported to the Nursing Home Administrator or the State agency until six days after it occurred. The delay in reporting this incident constitutes a deficiency in the facility's adherence to its policy on reporting abuse and neglect.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure that a resident received prescribed medications as ordered by the physician. On July 10, 2024, during the evening medication pass, a resident did not receive their prescribed doses of Tramadol HCL 50 mg and Lorazepam 0.25 mg. The medications were not administered as the medication cart was left open and unlocked, and the medications were removed by the RN Supervisor. The facility's policy requires that medication carts be kept closed and locked when not in use, which was not adhered to in this instance. The resident involved had diagnoses including dementia, major depressive disorder, and anxiety disorder, with a BIMS score indicating severe cognitive impairment. The resident's physician orders included Lorazepam to be given twice daily for anxiety and Tramadol three times daily for pain. However, the medication administration record showed that the resident did not receive the scheduled doses on the evening of July 10, 2024. The Med Tech documented that the medications were not available, which was later confirmed by the Controlled Drug Receipt Record. The incident was further complicated by the actions of the RN Supervisor, who removed the medication cards from the cart as a purported lesson to the Med Tech. This action resulted in the resident missing their scheduled doses. The Med Tech reported the missing medications to the pharmacy and the RN Supervisor, who then returned the medication cards and instructed the Med Tech to administer the medications, albeit an hour later than scheduled. This incident was reported to the facility's administration, including the Nursing Home Administrator and Director of Nursing.
Inadequate Water Management Plan and Infection Control
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically in relation to its Water Management Plan (WMP). The WMP was not based on current standards of practice and lacked critical components such as identifying all locations where Legionella could grow and spread, and specifying control measures and monitoring protocols. The plan also failed to document facility-specific control measures for managing health care-acquired legionellosis, despite the presence of Legionella in the water system. The facility's response to a Legionella diagnosis included inadequate measures such as using water coolers not specifically brought in for control purposes, which were later identified as a potential bacterial concern. The facility's WMP was outdated and did not reflect the current team members responsible for its implementation. The revised plan only updated the names of the program team members without addressing the deficiencies in the plan itself. The Assistant Nursing Home Administrator admitted that the only changes made were to update the program team, indicating a lack of comprehensive review and update of the WMP. Furthermore, the Director of Maintenance was unaware of the WMP and had not received adequate training, highlighting a gap in knowledge and implementation of the infection control measures. The facility's water system was not maintained according to the documented control measures, with discrepancies in water temperature management and monitoring. The hot water system was not maintained at the temperatures specified in the WMP, and the facility failed to identify and address potential risk areas such as dead legs and infrequently used equipment. The facility's documentation and monitoring practices were inconsistent, with tasks being completed outside of the scheduled intervals and lacking specific details about the equipment and procedures involved. These deficiencies in the WMP and its implementation posed a risk of Legionella growth and spread within the facility.
Failure to Ensure Proper Use of Palm Protectors for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. The resident, who has a history of Bipolar Disorder, Idiopathic Peripheral Autonomic Neuropathy, Type 2 Diabetes Mellitus, Morbid Obesity, Hypertension, Cerebral Infarction, and Disruptive Mood Dysregulation Disorder, was observed multiple times without the prescribed palm protectors. These protectors were part of a restorative program to prevent further loss of movement and ensure proper limb alignment. During the survey, the resident was observed on several occasions without the palm protectors, despite the care plan and treatment administration record indicating they should be applied daily. The resident reported not knowing the whereabouts of the splints and was seen without them during various activities, including eating and sitting outside. The Therapy Director confirmed that the resident should be wearing the palm protectors, and there were no recent changes in the therapy recommendations. The facility's documentation, including the Treatment Administration Record and Point Click Care tasks, indicated that the palm protectors were applied, but there was no documentation of refusal by the resident. The Assistant Director of Nursing acknowledged the resident's preference not to wear the protectors due to frequent snacking but noted a lack of proper documentation regarding the refusal. This discrepancy between the documented care and the actual observations highlights a deficiency in the facility's adherence to the care plan and documentation practices.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45% during a medication pass affecting one resident. The deficiency was identified when a Licensed Practical Nurse (LPN) administered medications to a resident, including Cinacalcet and Pantoprazole, which were crushed despite being contraindicated. The facility's policy clearly states that certain medications should not be crushed due to their formulation, such as delayed-release tablets, which are designed to release medication over a sustained period. The LPN crushed all tablets except for Gabapentin and Terazosin capsules, which were opened and mixed with applesauce for administration. The resident's physician order allowed for medications to be crushed unless contraindicated, yet the LPN proceeded to crush medications that were explicitly labeled not to be crushed. The surveyor observed this error and brought it to the attention of the LPN, who acknowledged the mistake. The Assistant Director of Nursing was also informed of the medication error rate and the specific incident, but no additional information or corrective actions were provided at the time of the survey.
Failure to Label Insulin with Expiration Dates
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional standards of practice, specifically regarding the expiration dates of insulin for two residents. During an observation, it was found that insulin vials for two residents were opened and used but not dated when opened, which is against the facility's policy and professional guidelines. The policy requires that the date opened and the triggered expiration date be recorded on multidose vials, but this was not adhered to for the insulin vials observed. The surveyor observed that the insulin vials for one resident included Lantus and Humalog, both of which were opened and used without being dated. Similarly, a Humulin 70/30 Kwik pen for another resident was also opened and used without a recorded date, despite the label indicating it expires 10 days after opening. The staff, including an LPN and the Assistant Director of Nursing, were unable to provide additional information or ensure compliance with the labeling requirements during the surveyor's observations.
Failure to Report Allegation of Exploitation
Penalty
Summary
The facility failed to report an allegation of exploitation involving a resident and a staff member to the State Survey Agency. The incident began when a resident was informed by an unknown CNA about rumors of a romantic relationship and gift-giving between the resident and an LPN. This led the resident to call the police. The resident later reported to the DON that they had bought various gifts for the LPN, but the facility did not identify this as an allegation of exploitation and did not report it to the State Survey Agency as required by their policy. The resident, who was cognitively intact according to their MDS assessment, denied buying gifts or having a relationship with the LPN when interviewed by the surveyor. However, the LPN stated that the resident had become increasingly obsessed with her and had expressed a desire to buy her gifts, which she declined. The LPN also mentioned that the facility leadership was aware of the resident's fixation. Despite this, the DON did not believe the allegation of gift-giving was valid due to the resident's mental state and did not report it. The surveyor's review of progress notes and interviews with facility staff revealed that the incident was not reported to the State Survey Agency. The DON and NHA were aware of the resident's claims but did not follow the facility's policy for reporting such allegations. The facility's grievance log also did not show any grievance filed by the resident regarding this issue. The failure to report the allegation of exploitation constitutes a deficiency in the facility's compliance with state and federal regulations.
Failure to Investigate Allegations of Exploitation
Penalty
Summary
The facility failed to ensure all allegations involving potential abuse, neglect, misappropriation, injuries of unknown origin, and exploitation were thoroughly investigated for one resident. The resident, who was cognitively intact, reported to a staff member that a CNA had mentioned rumors about the resident having a romantic relationship and buying gifts for an LPN. This information was not reported to the administration, and no investigation was initiated as required by the facility's policy. The resident later called the police, which brought the situation to the administration's attention, but still, no thorough investigation was conducted into the allegations of exploitation. The Director of Nursing (DON) was aware of the resident's report of buying gifts for the LPN but did not believe the allegation would be substantiated and only spoke to the LPN without conducting a full investigation. The Nursing Home Administrator (NHA) was also aware of the resident's call to the police but did not know about the specific allegation of gift-giving. The facility's grievance log did not contain any entries from the resident regarding this issue, indicating that the grievance was not formally documented or investigated. During interviews, the DON and NHA provided inconsistent accounts of the events and actions taken. The DON admitted to not completing a thorough investigation, and the NHA directed the surveyor to speak to the Assistant Nursing Home Administrator (ANHA) when asked about the protocol for handling such allegations. The facility's failure to follow its policy and conduct a comprehensive investigation into the allegations of exploitation led to the deficiency noted in the report.
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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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