Rivers Edge Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Muscoda, Wisconsin.
- Location
- 1000 N. Wisconsin Ave., Muscoda, Wisconsin 53573
- CMS Provider Number
- 525321
- Inspections on file
- 40
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 45 (1 serious)
Citation history
Health deficiencies cited at Rivers Edge Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to follow its abuse/neglect policy requiring notification of law enforcement for alleged violations when a resident with severe cognitive impairment slapped another cognitively impaired resident in the face in a common area. Staff witnessed the altercation, intervened immediately, and nursing assessed the affected resident with no injuries noted. The incident was self‑reported to the state, but the NHA documented that law enforcement was not contacted and later acknowledged that law enforcement should have been notified and that this step was forgotten.
A resident with severe cognitive impairment, multiple comorbidities, and a high fall risk had care-planned fall precautions, including a requirement to remain within line of sight when up in a Broda chair and to receive frequent neuro checks after falls. Despite this, the resident experienced multiple unwitnessed falls, including one from a wheelchair in a hallway while staff were at the nurses’ station and not continuously observing her, indicating the line-of-sight intervention was not maintained. After this unwitnessed fall, the resident was found with a forehead hematoma and pain, but neuro assessments were repeatedly documented as "asleep" and were not completed at times when the resident was known to be awake, contrary to facility policy and staff statements that a proper neuro exam requires waking the resident and assessing pupils and other parameters.
A resident with dementia and moderate cognitive impairment was slapped in the face by another resident with dementia while sitting in a lobby area. Nursing staff immediately assessed the affected resident and found no physical injury but documented that the resident was shaken and worried she had done something wrong, repeatedly bringing up the incident for several hours. Facility policies required protection from psychosocial harm and provision of medically related social services, including emotional support, counseling, and documentation in the medical record. The SW, DON, and NHA all acknowledged that psychosocial follow-up and documentation should have occurred, but there was no documented psychosocial assessment or social services intervention related to the incident, resulting in a deficiency for failure to provide medically related social services.
A resident with multiple cardiac and pulmonary diagnoses, including CHF, HTN, and A-fib, had an order for Metoprolol Succinate ER 150 mg daily with instructions to hold the dose if SBP was below 110 or HR below 55. Over a period of weeks, staff documented at least 20 administrations of this medication when the resident’s SBP was below the ordered parameter, as shown on the MAR. Interviews with a med tech, an RN, the NHA, and the DON confirmed that vital sign parameters are displayed in the MAR, that medications should be held when parameters are not met, and that such administrations are considered medication errors, yet the medication was still given on multiple occasions with low SBP.
A resident with impaired mobility and a history of falls did not have a required floor mat in place as a fall prevention intervention while in bed. After being found outside the facility and later on the floor in his room, staff failed to document the fall, complete a fall investigation, or notify the physician as required by facility policy.
A resident with moderate cognitive impairment and multiple health conditions alleged to hospital staff that a nurse had thrown him onto his bed. The facility administrator received this report but, after speaking with involved staff and the resident, did not report the allegation to the state agency or law enforcement as required by policy.
A resident with multiple medical and mental health conditions reported to hospital staff that a nurse had thrown him on the bed. The Nursing Home Administrator was notified and spoke with the involved nurse, CNA, and the resident, but did not interview other staff or residents. The investigation was not thorough, as required by facility policy and regulations.
A resident with severe cognitive impairment made inappropriate sexual remarks and verbalized intentions of sexual misconduct toward an LPN in a shared area, with other residents and staff present. Although law enforcement was involved and another resident was removed, the facility did not update the resident's care plan to address or monitor these behaviors, and no interventions were implemented.
Two residents experienced significant deficiencies in care, including failure by nursing staff to assess and monitor a change in condition despite reports from CNAs, incomplete documentation of intake and output, and lack of timely provider notification. One resident deteriorated over several days and died after being hospitalized for severe sepsis and UTI. Another resident underwent straight catheterization by an LPN without a physician’s order and had wounds that were not consistently assessed or treated per orders. These actions and inactions were not consistent with professional standards of practice.
Staff observed a CNA recording a resident with Parkinson's disease and encouraging the resident to dance in a manner perceived as demeaning. Despite staff concerns and facility policy requiring immediate reporting of alleged abuse, the administrator did not report the incident to the State Survey Agency after an internal investigation failed to substantiate the claim.
The facility did not conduct thorough investigations into allegations of abuse and neglect involving two residents. In one case, a CNA reported verbal and sexual abuse, but not all involved staff or residents were interviewed. In another case, a resident died from sepsis after a change in condition, but the facility's investigation lacked staff interviews and care audits. These actions did not meet the facility's policy for investigating such incidents.
A resident who is totally dependent for transfers was assisted with a Hoyer lift by only one CNA, contrary to facility policy and the resident's care plan, which require two staff for all mechanical lift transfers. The CNA acknowledged sometimes transferring the resident alone due to staffing shortages, and both the DON and NHA confirmed that the expectation is for two staff to be present during such transfers.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating a failure to maintain proper accuracy in medication administration.
A registered nurse was observed crushing and administering an extended-release Divalproex tablet to a resident for seizure management, contrary to physician orders and facility policy, which prohibit crushing extended-release medications.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident experienced a significant medication error due to a failure in the medication administration process.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
The facility did not notify law enforcement after an allegation that a nurse misappropriated a resident's narcotic medication, despite conducting an internal investigation and reporting the incident to the State Agency. The NHA confirmed that police notification was required but was not completed.
The facility did not provide complete discharge documentation for three residents who were transferred to other care settings or discharged home. In each case, required sections of the discharge summary were left incomplete, and essential information such as care during stay, recapitulation of illness, and discharge planning was missing. The lack of coordination and documentation was confirmed by the DON, and in one instance, the discharge was delayed due to confusion over procedures and missing information.
Staff did not follow proper hand hygiene and standard precautions during catheter care for two residents with indwelling catheters, including failing to change gloves and use barriers when required, and not adhering to facility policy or CDC guidelines. Both a CNA and an LPN admitted to lapses in infection control practices during care, and the DON was unsure if her instructions to staff aligned with CDC recommendations.
A resident with multiple complex medical conditions did not receive several scheduled medications on multiple days, including when leaving for an appointment, and there was missing documentation in the MAR. Medications were also administered late or at the same time as other scheduled doses, contrary to facility policy. Staff interviews confirmed that required procedures for medication administration and documentation were not consistently followed, and no progress notes explained the omissions.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with an indwelling Foley catheter, at risk for infection, was placed on Enhanced Barrier Precautions (EBP) per care plan and physician orders. Despite clear signage and policy requiring gloves and gowns for high-contact care activities, an LPN was observed performing catheter care and changing briefs without wearing a gown. The LPN acknowledged knowledge of the EBP protocol but did not comply, and the DON confirmed staff had been educated on these requirements.
The facility did not ensure that daily nurse staffing postings accurately reflected the actual staff working each shift, with discrepancies found between posted information and schedules. Staff responsible for postings included the DON even when not providing direct care, and both the staff member and administrator confirmed the postings were inaccurate, affecting the reported staffing for all residents.
Three residents experienced significant harm due to the facility's failure to follow professional standards of practice, including not completing RN assessments, not following provider orders, and not documenting or implementing required care. One resident swallowed a foreign object and was not properly assessed or sent to the hospital promptly, resulting in a surgical intervention. Another resident's foot infection progressed to gangrene and amputation due to delayed antibiotics and lack of wound care. A third resident's vascular ulcer worsened and became infected after missed treatments and delayed antibiotics, leading to hospitalization.
Two residents were not provided with adequate supervision or a safe environment, resulting in one resident suffering a hip fracture after repeated unwitnessed falls despite a PT's recommendation for 1:1 supervision, and another resident charging a power wheelchair in their room without a facility policy or proper safety measures in place.
Surveyors found that food items, including milk, mandarin oranges, barbecue sauce, and magic cups, were opened or removed from original packaging without required open or thaw dates. The Dietary Manager and other staff confirmed that these items should have been labeled according to facility policy, but could not verify when they were opened or thawed. This failure to properly date mark food had the potential to affect all residents.
Surveyors found that multiple residents lived in unclean and cluttered rooms, with soiled linens, debris, and personal items scattered on the floors. Several residents and their representatives reported dissatisfaction with the cleanliness of rooms and equipment, such as wheelchairs, which were observed to be dirty. Staff interviews revealed confusion about cleaning responsibilities, and maintenance issues like water-damaged ceilings and cobwebs were also present.
The facility did not ensure that alternatives were attempted before installing bed rails, failed to assess and document entrapment risks—especially with air mattresses—and did not provide or document education, risk/benefit review, or informed consent for several residents. Staff interviews revealed confusion over responsibilities, and there was no evidence of required safety checks or ongoing monitoring, resulting in multiple deficiencies in bed rail safety.
Surveyors found that food and drink, specifically milk, were served to residents at unsafe temperatures above the required 41°F, with the milk tasting warm. The Dietary Manager demonstrated a misunderstanding of safe temperature ranges, and facility practices did not align with established food safety policies, as no plate warmers or ice were used to maintain proper temperatures.
A resident with significant medical needs reported a missing clothing item to laundry staff, but the complaint was not documented, investigated, or escalated according to facility grievance policy. Staff did not keep a log of lost items or follow the required process, resulting in the grievance remaining unresolved for an extended period.
A resident with multiple risk factors for pressure ulcers returned from two hospitalizations without having the required full body skin assessments completed by nursing staff, as mandated by facility policy. Documentation and staff interviews confirmed that these assessments were not performed, despite the resident's ongoing risk and changes in wound condition.
Two residents with diabetes did not consistently receive routine foot checks as ordered by physicians and required by facility policy. Documentation showed multiple missed foot checks, and staff interviews confirmed that checks were sometimes not performed or were rushed. In one case, a podiatry dressing remained unchanged for several days despite documentation indicating foot checks had been completed.
A resident with a history of diabetes, ankle fracture, and dementia was prescribed an antibiotic for toe cellulitis following an ER visit, but the facility delayed entering the order and administering the first dose, resulting in a significant medication error.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents requiring infection control measures. In one case, two CNAs assisted a resident with a urinary catheter during a transfer and personal care without wearing gloves or gowns. In another case, the Interim DON removed a wound dressing from a resident with multiple ulcers without wearing a gown, despite facility policy requiring both gown and gloves for such care.
A resident with severe cognitive impairment and multiple medical conditions had ongoing care concerns voiced by their POA, particularly about hydration. The facility did not document, investigate, or resolve these grievances as required by its policy, and leadership could not provide grievance records for the relevant period.
The facility did not conduct complete investigations or timely reporting for multiple abuse allegations, including failure to interview all potentially affected residents and lack of documented psychosocial assessments. In each case, required final reports were not submitted to the State Agency within the mandated timeframe.
A resident with complex medical needs did not receive all prescribed doses of cancer and pain medications due to missed administrations and incomplete documentation on the MAR. Nursing staff interviews confirmed that blank entries and unexplained codes indicated medications were not given, and required nurse's notes were often missing. Issues with prior authorization for pain medication and inconsistent adherence to medication administration policies contributed to the deficiency.
A resident's request to change their primary care physician was not honored due to the facility's extensive and prohibitive requirements for the new physician. Despite the resident's cognitive intactness and expressed dissatisfaction with the current physician, the facility's demands for documentation and lack of follow-up communication hindered the process. The new physician found the requirements excessive and declined to proceed, leaving the resident with the facility's medical director as their PCP.
A resident with cognitive impairment was verbally abused by a housekeeper, who used offensive language and engaged in a confrontational manner. Despite the presence of staff, the situation was not adequately de-escalated, and the resident was not protected from the abuse. The incident was reported, but staff failed to intervene effectively, highlighting a deficiency in the facility's abuse prevention measures.
The facility failed to report alleged abuse incidents involving two residents to the State Agency within the required timeframe. One resident, with moderate cognitive impairment, reported a CNA threatened him with a gun, but the report was delayed. Another resident, cognitively intact, reported a nurse threw a cup at him, but the facility did not report or investigate the allegation. The facility did not adhere to its policy and state reporting requirements.
The facility failed to thoroughly investigate abuse allegations for three residents. One resident was verbally abused by a staff member, but key witness statements were missing, and staff re-education was inadequate. Another resident's abuse allegation was not fully investigated as the resident was not interviewed. A third resident's report of a nurse throwing a cup was not investigated due to lack of awareness by the DON.
A resident with cancer and diabetes did not receive nine medications over two days and one medication on another day due to pharmacy issues, as indicated by blanks on the MAR. Interviews with the resident, an LPN, and the CND revealed that the facility failed to document the reasons for non-administration and did not follow procedures to ensure medication availability and administration.
A resident with dementia and a history of expressing a desire to leave the facility eloped, traveling approximately 70 miles away, due to inadequate supervision and lack of a proper elopement risk assessment. The resident left unnoticed by staff and was not located until hours later by law enforcement. The facility failed to implement its elopement policy effectively, as no formal assessment or care plan update was conducted, and 30-minute checks were discontinued without proper evaluation.
A facility failed to prevent significant medication errors for four residents. One resident received an incorrect medication, leading to hospitalization. Two residents missed doses of critical medications due to documentation errors and lack of follow-up on insurance issues. Another resident experienced a delay in receiving prescribed medication after admission. Staff interviews confirmed these errors, highlighting the facility's responsibility to ensure proper medication administration.
The facility did not ensure that food and drink were served at safe and appetizing temperatures, affecting one hall and a test tray. A surveyor found that hot foods were served below the required temperatures, and a cold beverage was served above the safe limit. The Dietary Manager acknowledged the issue, confirming that meal trays should meet the facility's temperature standards.
A CNA in a LTC facility took humiliating pictures of a resident with severe cognitive impairment and shared them with staff, violating the facility's abuse policy. The incident was reported, but there was disagreement among staff about whether it constituted abuse. The facility failed to document the incident in the resident's medical record and did not complete staff education on abuse prevention.
A facility failed to report an alleged abuse incident within the required timeframe. A CNA took inappropriate photos of residents, which were shown to other staff. Despite awareness, staff did not report the incident promptly to the NHA or State Agency. The facility's policy on abuse was not followed, as staff did not recognize the act as abuse or a violation of residents' rights. The DON was aware of the policy against cell phones in care areas, but it was not enforced effectively.
A facility failed to thoroughly investigate an allegation of abuse/exploitation involving a CNA taking unauthorized photos of residents. The CNA took pictures to document poor care, believing it was permissible if no faces or private areas were shown. The facility's investigation did not include questions about inappropriate picture-taking, indicating a failure to follow policy on conducting comprehensive investigations.
Failure to Notify Law Enforcement of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving two residents was reported to law enforcement as required by facility policy and regulatory expectations. The facility’s Abuse/Neglect/Exploitation policy, dated 11/2017, states that all alleged violations are to be reported to the Administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable, within specified timeframes. A misconduct incident report submitted on 12/30/25 documented that one resident (R4), who had dementia with severe cognitive impairment per an admission MDS assessment, slapped another resident (R3) in the face while R3 was sitting in the lobby and R4 was walking to the dining room. Staff witnessed the event, immediately intervened, and nursing assessed R3, with no injuries noted. The incident report identified R3 as the affected person and R4 as the accused person. The same misconduct incident report indicated that law enforcement was not contacted regarding this resident‑to‑resident altercation. During an interview on 1/21/26, the Nursing Home Administrator (NHA A), who prepared and submitted the misconduct incident report, stated that law enforcement should be notified with every facility self‑report and acknowledged that law enforcement had not been notified for this incident and that it “should have been,” attributing the omission to it having been forgotten. As a result, the alleged abuse incident involving R3 and R4 was not reported to law enforcement in accordance with the facility’s written procedures and reporting requirements.
Failure to Maintain Line-of-Sight Supervision and Complete Neuro Checks After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall-prevention interventions for a resident at high risk for falls, as well as failure to complete required neurological assessments after an unwitnessed fall with head injury. The resident had multiple diagnoses including inflammatory spondylopathy of the lumbar region, COPD, acute on chronic systolic CHF, type 2 diabetes with diabetic polyneuropathy, post-stroke cognitive symptoms, muscle wasting and atrophy, unsteadiness on feet, and bilateral age-related cataracts. An MDS assessment showed a BIMS score of 99, indicating severe cognitive impairment. Fall Risk Evaluations conducted on several dates showed the resident was consistently at risk for falls, with scores of 10, 19, 15, and 11. The resident’s care plan identified her as at risk for falls related to medications, dizziness, cognitive impairment, and unawareness of safety, and included multiple interventions such as use of an appropriately sized Broda chair, environmental monitoring, low bed position, call light within reach, use of a gait belt, and later, a “Falling Star” check every 60 minutes. Following an unwitnessed fall on 9/25, the resident’s care plan was updated on 9/26 to include the specific intervention that she must remain within eyesight when up in her Broda chair. Additional fall-related care plan updates on 9/28 included directions to evaluate fall risk on admission and as needed, to alert the provider if a fall occurs, and to initiate frequent neurological and bleeding evaluations per facility protocol after a fall. The facility’s Fall Management Process policy required a complete head-to-toe assessment before moving a resident after a fall, neurological checks for any unwitnessed fall or any fall with evidence of head injury, and documentation of physician and family notification. Despite these policies and care plan directives, the resident experienced further unwitnessed falls, including one on 11/1 while walking unsupervised in her room and attempting to self-transfer from bed, and another on 11/2 when she fell from her wheelchair in the hallway. On the night of 11/2, the resident was in her Broda chair and was supposed to be kept within line of sight of staff per her care plan. A CNA’s written statement indicates the CNA and another staff member were at the nurses’ station gathering paperwork while the resident was on the other side of the nurses’ station near the medication cart and within the CNA’s view. The CNA reported that less than five minutes after last seeing the resident, she noticed the resident was no longer by the medication cart, saw the wheelchair down the hall without the resident in it, and then found the resident lying on her right side on the floor in front of a room. A progress note documented that the fall was unwitnessed and occurred in the hallway. A subsequent assessment identified a hematoma on the resident’s forehead measuring 6.5 x 5 (unit not specified), and progress notes documented the presence of pain. Although neurological assessment forms were completed at multiple time points, many entries simply recorded the resident as “asleep” for all categories, and there were no neurological assessments documented at specific times when the resident was known to be awake (such as when she received morphine and lorazepam or when she self-transferred to the bathroom). Interviews with facility staff, including a medication tech, an RN, the NHA, and the DON, confirmed that “in line of sight” means staff must be able to physically see the resident, and that a proper neurological exam cannot be performed if the resident is asleep because pupils and other parameters must be assessed. The surveyor noted that the facility could not provide documentation showing the resident was in line of sight at the time of the fall from the Broda chair, and that neurological checks were not completed in accordance with policy after the unwitnessed fall with head injury. Interviews with the NHA and DON further confirmed that residents with fall precautions are identified by star pictures on their doors and interventions listed on care plans and closet Kardexes, and that residents with “in line of sight” interventions must be physically visible to staff. The DON stated she would wake a resident to complete a neurological assessment because otherwise she would not know if there had been a change in mental status, and she identified pupil size and vital signs as pertinent findings on neurological assessments. Despite these expectations, the documentation for this resident showed repeated use of “asleep” entries in place of full neurological assessments, even after an unwitnessed fall with a documented forehead hematoma. The surveyor allowed additional time for the NHA and DON to locate any alternative evidence that the resident had been kept within line of sight at the time of the 11/2 fall, but none was provided. These findings demonstrate that the facility did not ensure the resident received adequate supervision in accordance with her care plan and did not complete neurological checks as required by facility policy after an unwitnessed fall with evidence of head injury.
Failure to Provide and Document Psychosocial Follow-Up After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services and psychosocial follow-up to a resident after a resident-to-resident altercation. Facility policy on Abuse/Neglect/Exploitation requires protection of residents from physical and psychosocial harm during and after an investigation, including providing emotional support and counseling. The Social Services Director policy further requires identification and provision of medically related social services and adequate documentation of social services actions in the medical record. Despite these policies, there was no documented psychosocial assessment or follow-up for the affected resident after the incident. The incident occurred when one resident with dementia (R4) walked into the lobby and slapped another resident (R3) in the face while R3 was sitting in the lobby. Staff witnessed the event, immediately removed R4, and nursing assessed R3, documenting no physical injuries but noting that R3 was “shaken up.” The facility’s Misconduct Incident Report recorded that R3 was concerned she had done something wrong, required reassurance that she was safe, and continued to bring up the incident for a few hours afterward before forgetting about it. R3’s medical record, including a progress note from the date of the incident, documented the physical assessment and that she was shaken, but contained no follow-up documentation addressing her psychosocial needs related to the altercation. R3 had been admitted with dementia and associated psychotic, mood, and anxiety disturbances, and her most recent MDS showed moderate cognitive impairment. During interviews, the social worker stated she had heard about the incident but was not directly informed of her role, was unsure what her responsibilities would be, and acknowledged that any conversations she had with R3 about the incident were general and not documented. The DON and the Nursing Home Administrator both acknowledged awareness of the incident and indicated they would have expected psychosocial follow-up and documentation for R3 after the altercation. The absence of documented psychosocial assessment or follow-up, despite policies requiring such services and the resident’s expressed distress, formed the basis of the cited deficiency.
Repeated Administration of Metoprolol Outside Ordered Blood Pressure Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of Metoprolol Succinate. The resident had a physician’s order for Metoprolol Succinate ER 150 mg by mouth once daily for essential hypertension, with explicit parameters to hold the medication if the systolic blood pressure (SBP) was below 110 or the heart rate (HR) was below 55. Despite this order, the Medication Administration Record (MAR) shows that nursing staff repeatedly administered the medication when the resident’s SBP was below the ordered threshold. The facility’s own “Medication Errors” policy defines a medication error as administration not in accordance with the prescriber’s order and states that the facility shall ensure medications are administered according to physician orders. The resident involved was admitted with multiple diagnoses, including secondary parkinsonism, COPD, type 2 diabetes mellitus, acute on chronic systolic congestive heart failure, essential hypertension, atrial fibrillation, and a coronary angioplasty implant and graft. A recent BIMS score of 15/15 indicated the resident was cognitively intact. The MAR documented that Metoprolol Succinate was administered on at least 14 occasions in December and 6 occasions in January with SBP readings below 110, including readings such as 91/45, 98/47, 88/58, and several others under the ordered SBP parameter. These administrations were counted as 20 significant medication errors between early December and late January, as they did not follow the physician’s hold parameters. Interviews with staff and leadership further established that the facility’s processes and staff knowledge acknowledged the requirement to follow vital sign parameters but did not prevent or correct the repeated errors. A medication tech stated that the MAR displays vital sign parameters, that medications should be held when vital signs fall outside those parameters, and that any such occurrence should be reported to the charge nurse with physician notification and monitoring. An RN who frequently worked on the resident’s hall confirmed that vital sign parameters are listed in the MAR, that medications should be held when parameters are not met, and that if a medication is given despite out-of-range vital signs, the physician should be called and the resident closely monitored. The NHA and DON both stated that parameters are written on the MAR, that medications should be held and physicians notified when parameters are not met, and agreed that the administrations in question were medication errors and that the Metoprolol should have been held on those occasions. Despite this, the MAR shows the medication was administered multiple times with SBP below the ordered threshold, constituting the cited deficiency.
Failure to Implement Fall Prevention Interventions and Complete Required Fall Investigation
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and that fall prevention interventions were in place, as required by facility policy. A resident with a history of falls, bilateral amputation, impaired mobility, and cognitive intactness was care planned to have a floor mat and Dycem in the wheelchair seat as fall interventions. On observation, the floor mat was not in place while the resident was in bed, and staff confirmed that it should have been present according to the care plan. The Director of Nursing acknowledged that the intervention was missing and that staff education would be initiated. Additionally, the resident experienced an incident where he was found outside the facility in his wheelchair, appeared intoxicated, and later was found on the floor in his room. Staff interviews and documentation revealed that after the resident was assessed and returned to bed, there was no mention of a fall in the progress notes, and the required fall investigation was not completed. The nurse involved did not document the fall or complete the necessary event documentation, fall risk assessment, or pain assessment as outlined in the facility's Falls Management Process policy. Furthermore, the physician was not updated regarding the fall, as required by facility policy. The only communication to the physician referenced the resident's intoxication and return to the facility, with no mention of the fall event. The Director of Nursing confirmed that a fall investigation should have been completed and that the physician should have been notified, but these actions were not taken at the time of the incident.
Failure to Report Alleged Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency and law enforcement as required by policy. Specifically, a resident with a history of bipolar disorder, antisocial personality disorder, kidney disease, and diabetes, who was moderately cognitively impaired, reported to hospital staff that a nurse at the facility had thrown him onto his bed. This allegation was communicated to the facility's Nursing Home Administrator (NHA) by a hospital care coordinator. The NHA acknowledged receiving the report and stated she would follow up. Upon receiving the allegation, the NHA spoke with the nurse and CNA who were present during the incident, and their statements matched. The NHA also spoke with the resident, who expressed no current concerns, felt safe, and could not recall the incident. Despite recognizing that the resident's statement could be considered an allegation of abuse and should be investigated and reported, the NHA did not report the incident to the state agency or law enforcement. This omission was identified during a review of five investigations, with this case being the only one where the required reporting did not occur.
Failure to Thoroughly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of abuse as required by policy and regulation. A resident with a history of bipolar disorder, antisocial personality disorder, kidney disease, and diabetes, who was moderately cognitively impaired and had an activated power of attorney, reported to hospital staff that a nurse at the facility had thrown him on the bed. The hospital care coordinator communicated this concern to the Nursing Home Administrator (NHA), who stated she would follow up and report back. The NHA spoke with the nurse and CNA who were working with the resident on the night in question, and their statements matched. The NHA also spoke with the resident, who did not recall the incident and expressed feeling safe at the facility. However, the NHA did not conduct further investigation, such as interviewing other residents or staff. The NHA acknowledged that the resident's statement could be considered an allegation of abuse and should have been thoroughly investigated, but this was not completed.
Failure to Develop Behavior Care Plan for Inappropriate Sexual Conduct
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the behavioral needs of a resident who exhibited inappropriate sexual behaviors. Specifically, a resident with severe cognitive impairment, as indicated by a BIMS score of 8 out of 15, was involved in an incident where he made sexual remarks and verbalized intentions of sexual misconduct toward an LPN in a shared gathering room. The incident was witnessed by other residents and staff, and law enforcement was involved, resulting in the arrest and removal of another resident who also participated in the behavior. Despite the incident and the resident's documented cognitive impairment, the facility did not update the resident's comprehensive care plan to include goals or interventions related to inappropriate sexual behaviors. The care plan, last reviewed after the incident, lacked any mention of monitoring or addressing such behaviors. Facility leadership acknowledged that no interventions or monitoring had been implemented for the resident's inappropriate sexual comments, despite recognizing that such measures should have been in place.
Failure to Recognize and Respond to Change of Condition and Inadequate Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents who experienced changes in condition. For one resident with a history of Alzheimer’s disease, kidney disease, and an indwelling Foley catheter, multiple CNAs observed and reported significant changes including increased lethargy, decreased intake, and changes in urine color and output. Despite these reports, nursing staff did not complete a nursing assessment, did not monitor the resident’s condition, and did not notify the provider of the changes. Documentation of intake and output was inconsistent and incomplete, with staff using non-quantitative symbols instead of actual measurements, making it impossible to determine the resident’s fluid status. The resident’s condition deteriorated over several days, culminating in hospitalization for severe sepsis, bacteremia, and UTI, and ultimately resulted in death. Another resident was subjected to a straight catheterization by an LPN to obtain a urine sample without a physician’s order, which is not permitted by professional standards or facility policy. The resident reported pain and discomfort from the procedure, which was attempted multiple times, including one attempt that resulted in a contaminated sample. Additionally, this resident had multiple wounds that were not consistently assessed or measured, and there was no documentation of an admission skin assessment or classification of the wounds. Physician orders for wound care were not consistently followed, and wound documentation was incomplete and lacked necessary details such as tunneling and depth. Interviews with staff and review of facility documentation revealed a lack of clear responsibility for monitoring intake and output, inconsistent documentation practices, and failures to notify providers of significant changes in residents’ conditions. The facility’s own policies required immediate notification of changes in condition and adherence to the nursing process, but these were not followed. These failures resulted in immediate jeopardy for one resident and demonstrated a pattern of deficient practice in the recognition, assessment, and management of changes in condition and wound care.
Removal Plan
- Educate all nursing staff, including agency, on recognition of change of condition and immediate reporting to the nurse. The nurse will perform a head to toe assessment and notify the PCP of findings.
- Educate staff on recognizing a change of condition, including changes in mental status, intake or output, urine color, communication, pain, swelling, weakness, and skin color. Use the stop and watch warning tool.
- Educate staff to report possible change of condition to the nurse immediately. The nurse will do a full assessment, call the MD, follow MD directions, document the change, notify the POA/MCO, continue monitoring, and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Educate nurses on completing a head to toe assessment, including vitals, pain, GI, respiratory, cardiac, GU symptoms, and immediate MD notification. Continue monitoring and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Train staff on properly recording fluid intake and food percentage for each resident on each shift. CNA assigned to the dining room will record all intakes and ensure residents eating in rooms are recorded. CNA is responsible for charting this information in the resident’s chart.
- Educate staff on recording intakes using the spreadsheet for each meal, properly documenting in the resident’s chart, noting if the amount is off baseline, and immediately reporting to the nurse.
- Educate staff to report immediately to the nurse if the resident’s intake or output has decreased.
- Educate staff on the 24-hour board binder and proper recording of change of condition to be reviewed during report off.
- Sweep the building for any changes in condition.
- Review policy related to changes of condition and notification of changes.
- Implement 24-hour board binder for monitoring and review during stand up.
- Implement process for monitoring fluid intake and output and when to notify MD/NP.
- Review head to toe and system-specific assessment for intake and output.
- Implement system to report off resident change of condition to next shift.
- The DON or designee will conduct audits of charting for change of condition and documentation.
- The DON or designee will conduct audits of the 24-hour report for properly completed and documented assessments and MD notification.
- The DON or designee will conduct audits to ensure changes of condition are recognized, assessments completed, and MD notification.
- The DON or designee will conduct audits of intake sheets and proper documentation in charts.
- The DON or designee will conduct audits of output documentation and proper reporting of inadequate output.
- The DON or designee will conduct audits of the intake sheet and proper documentation and reporting of decreased intake.
- The DON or designee will conduct audits on proper reporting of change of condition to the next shift.
- Review all facility actions, education, and audits at QAPI.
Failure to Report Alleged Mental Abuse Involving Resident Recording
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency as required. Multiple staff members, including CNAs and LPNs, witnessed a CNA taking videos and pictures of a resident with Parkinson's disease at the nurse's station. Staff statements indicated that the CNA was encouraging the resident to dance while recording, which was perceived by some staff as inappropriate and demeaning. Despite these observations and staff concerns, the administrator did not report the allegation to the State Survey Agency. The administrator acknowledged that recording a resident could be considered potential abuse but chose not to submit an initial abuse report after conducting an internal investigation and determining the allegation could not be substantiated. The facility's own abuse policy requires reporting all alleged violations to the appropriate authorities within specified timeframes, but this procedure was not followed. The resident involved has a guardian and was admitted with a diagnosis of Parkinson's disease. The failure to report the allegation was identified through staff interviews, record review, and an anonymous complaint received by the state agency.
Failure to Thoroughly Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for two of four residents reviewed. In the first instance, a certified nursing assistant (CNA) reported allegations of verbal and sexual abuse involving another CNA and a resident. The report included claims of inappropriate conduct, such as flirting and the exchange of food, as well as verbal mistreatment. The facility's investigation did not include interviews with all potentially involved staff or other residents who may have had relevant information. Specifically, the second CNA on duty during the alleged incident was not interviewed, and no other residents were questioned about the allegations. The nursing home administrator acknowledged that additional interviews should have been conducted to fully understand the scope of the allegations. In the second instance, a resident with multiple diagnoses, including severe cognitive impairment, experienced a change in condition that led to hospitalization and subsequent death from sepsis. The facility initiated a self-report investigation after learning of the resident's death and diagnosis of sepsis. However, the investigation did not include interviews with staff or audits of resident care, nor was any education provided regarding the incident. The nursing home administrator confirmed that no staff interviews or house audits were completed, and there was an expectation that nursing staff would report changes in condition and complete assessments. Surveyors found, through their own interviews and record review, concerns related to the resident's change of condition, assessments, and physician notification that were not addressed in the facility's investigation. Both cases demonstrate that the facility did not follow its own policy requiring immediate and thorough investigations of alleged abuse, neglect, or mistreatment. The investigations lacked comprehensive documentation, failed to identify and interview all involved persons, and did not fully determine the extent or cause of the alleged incidents. These deficiencies were identified through observation, interview, and record review by surveyors.
Failure to Ensure Two-Person Assistance During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when a resident who requires total assistance for transfers, as documented in their care plan and Minimum Data Set (MDS), was transferred using a Hoyer lift by only one Certified Nursing Assistant (CNA) instead of the required two staff members. The facility's policy and the resident's care plan both specify that all mechanical lift transfers must be performed with two staff to ensure safety. The resident, who has multiple diagnoses including spina bifida, diabetes mellitus, asthma, chronic heart failure, and a history of falls, reported to the surveyor that sometimes only one CNA assists with Hoyer lift transfers, particularly during the PM shift. During interviews, a CNA confirmed that due to staffing shortages, he sometimes performs Hoyer lift transfers alone, including with this resident, despite knowing the policy requires two staff. Both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated that they expect staff to follow the facility's policy and resident care plans, which mandate two staff for Hoyer lift transfers. The failure to consistently provide adequate supervision and follow established transfer protocols led to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Crushing and Administering Extended-Release Medication Without Order
Penalty
Summary
A significant medication error occurred when a registered nurse crushed and administered an extended-release Divalproex (Depakote) tablet to a resident, despite the medication being prescribed in its extended-release form for seizure management. Facility policy specifies that medications should be administered as ordered and in accordance with manufacturer specifications, which includes not crushing medications labeled as 'do not crush.' The resident's physician orders did not include instructions to crush the Divalproex extended-release tablet, and the Director of Nursing confirmed that there was no such order and that it is not acceptable to crush this medication. The error was directly observed by the surveyor during medication administration.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Law Enforcement of Medication Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving misappropriation of resident medications were reported to all required authorities. Specifically, when the facility became aware of an allegation that a nurse had signed out a resident's narcotic medication and placed the pill in her pocket, the facility initiated an investigation and submitted a Facility Reported Incident to the State Agency as required. However, the facility did not notify law enforcement about the incident, despite this being a requirement outlined in their own policy and acknowledged by the Nursing Home Administrator (NHA) during interview. The facility's policy mandates immediate reporting of all alleged violations, including misappropriation of resident property, to the administrator, state agency, adult protective services, and law enforcement when applicable. The surveyor's review of the investigation confirmed that while staff were educated and an internal investigation was conducted, the police were not contacted regarding the misappropriation of medication. The NHA confirmed during interview that law enforcement should have been notified in this case.
Failure to Provide Required Discharge Documentation for Multiple Residents
Penalty
Summary
The facility failed to provide proper discharge documentation for three out of four residents reviewed for discharge. In the case of one resident who was transferred to an assisted living facility, the discharge process was delayed by one to two weeks due to incomplete and unclear documentation, lack of coordination, and missing information in the discharge summary. The required sections of the discharge summary, such as care during stay, recapitulation of illness and treatment, functional status, and pre-discharge preparation, were not completed. The social services director, who was responsible for the discharge, did not document key aspects of the process and was reportedly unsure about the necessary procedures and the receiving facility. Another resident, who was discharged home, also did not receive a complete discharge summary. The documentation provided at discharge consisted only of an order summary with an active medication list, lacking details such as the date and time of last medication administration and a comprehensive recap of the resident's stay. The care plan did not address discharge planning, and the interdisciplinary discharge summary was left incomplete. The social worker, who was primarily responsible for discharge planning, was not available, and the director of nursing confirmed that the documentation was insufficient and incomplete. A third resident was transferred to a hospital, but the facility failed to document the transfer appropriately or communicate necessary information to the receiving provider. There was no completed discharge summary, no documentation of the reason for transfer, and no bed-hold notice or explanation regarding the resident's potential return. The progress notes did not address the discharge, and the interdisciplinary discharge summary remained unfinished. The director of nursing acknowledged the lack of documentation and information regarding the resident's transfer.
Failure to Follow Proper Catheter Care and Infection Prevention Protocols
Penalty
Summary
Staff failed to provide appropriate catheter care and infection prevention for two residents with indwelling urinary catheters. In one instance, a CNA performed suprapubic catheter care without following proper hand hygiene protocols, such as not changing gloves or performing hand hygiene when moving from dirty to clean tasks, and failed to use a barrier under the wash basin. The CNA also contaminated the wash basin by reaching into it with soiled gloves and admitted to not following correct procedures during an interview. The DON confirmed that hand hygiene should be performed before and after care and when moving from dirty to clean, and that a barrier should be used under the wash basin. In another case, an LPN provided catheter care to a resident with a history of chronic kidney disease, pyelitis cystica, and obstructive uropathy. The LPN did not don a gown, failed to change gloves or perform hand hygiene after picking up a cleansing wipe that had fallen into the toilet, and continued care without following standard precautions. The resident was found with urine-soaked clothing due to the catheter not being attached to the leg bag, and the stat lock and extension tubing were missing. The LPN admitted to not knowing the facility's catheter care policy and acknowledged that gloves should have been changed after handling the contaminated wipe. Facility policy and CDC guidelines require hand hygiene and standard precautions, including glove changes and the use of barriers, during catheter care to prevent infection. Both staff members failed to adhere to these protocols, as evidenced by their actions and their own admissions during interviews. The DON also stated that she teaches staff to triple glove and remove layers as they become soiled, but was unsure if this practice aligns with CDC recommendations.
Failure to Ensure Accurate and Timely Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate and timely administration of medications for one resident, resulting in multiple missed doses, late administrations, and incomplete documentation. The resident, who had diagnoses including type 2 diabetes, neoplasm-related pain, acute kidney failure, secondary breast cancer, bone cancer, depression, and anxiety disorder, did not receive her scheduled morning medications on several days, including when she left the facility for a pre-scheduled appointment. There was no documentation in the Medication Administration Record (MAR) for numerous medications on specific dates, and no progress notes explaining the omissions or the resident's absence from the facility. Further review of the MAR revealed that on one occasion, the resident received both her morning and afternoon medications at the same time, and several medications were administered outside the recommended time window, with some doses given four to seven hours late. The facility's medication administration policy requires medications to be given within one hour before or after the scheduled time, with immediate documentation and notation of any delays or omissions, but these procedures were not followed. Interviews with the DON and a Medication Technician confirmed that staff should check appointment logs and communication boards to ensure residents receive medications before leaving for appointments, but this process was not consistently implemented. The Director of Nursing acknowledged the missed medications and lack of documentation, agreeing that progress notes should have been made to explain the omissions. The DON also confirmed that medication administration times should reflect the actual time of administration, and that the facility's practices did not align with policy requirements. No additional documentation was provided to account for the missed or late medications, and the facility did not document any medication errors during the period in question.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. The facility's policy and physician orders required the use of gloves and gowns during high-contact care activities, such as changing briefs, toileting, and catheter care, for residents under EBP. Despite these requirements, a staff member was observed entering the resident's room and performing these high-contact care activities without donning a gown, as mandated by both facility policy and CDC guidelines. The resident involved had a medical history that included chronic kidney disease, pyelitis cystica, and obstructive and reflux uropathy, and was at increased risk for infection due to the presence of an indwelling Foley catheter. The resident's care plan and physician orders specifically called for EBP, including the use of appropriate PPE during high-contact care activities. A sign was posted on the resident's door indicating the need for gloves and gowns for such activities, yet this protocol was not followed during the observed care. Interviews with the LPN who provided care confirmed awareness of the EBP requirements but revealed non-compliance, as the LPN admitted to not wearing a gown during catheter care. The Director of Nursing also confirmed that staff had been educated on EBP protocols and that it was her expectation for staff to follow these precautions for residents with catheters or wounds. Despite this, the required infection control measures were not implemented during the observed incident.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that daily nurse staffing information postings were accurate, as required. Surveyors reviewed staffing schedules and posted staff information over a two-week period and found multiple discrepancies between the posted information and the actual schedules. For several days, the number and type of staff listed on the postings did not match the staff who actually worked, as indicated by the schedules. For example, postings often included staff such as RNs or Med Techs who were not present according to the schedule, or omitted staff who did work. Additionally, the Director of Nursing (DON) was included in the postings even when not providing direct patient care, contrary to requirements that only direct care staff be listed. During interviews, the staff member responsible for preparing the postings stated that she completed them based on the printed schedule and included the DON's hours regardless of whether direct care was provided. Both the staff member and the Nursing Home Administrator acknowledged that the postings and schedules were not accurate and did not match. These inaccuracies affected the reported total number and hours of licensed and non-licensed staff responsible for resident care on each shift, potentially impacting all 43 residents in the facility.
Failure to Provide Care Consistent with Standards of Practice Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents, resulting in significant adverse outcomes. In one case, a resident with a history of dysphagia, respiratory failure, and psychological disorder reported swallowing a stress ball. Staff did not contact poison control to determine the toxicity of the ball's contents, did not complete a Registered Nurse (RN) assessment including respiratory, abdominal, or pain assessments, and inaccurately reported to the Nurse Practitioner (NP) that the ball was retrieved without having it in possession. The resident requested to go to the hospital but was not sent until the following day, despite expressing distress and pain. Orders from the NP for close monitoring were not followed, and the resident's care plan was not updated to prevent recurrence. The resident ultimately developed a high-grade small bowel obstruction requiring surgical intervention and a six-day hospitalization. Another resident with diabetes and a history of serious ankle fracture developed cellulitis in the right third toe, which progressed to gangrene and possible osteomyelitis. The facility did not initiate the prescribed antibiotic in a timely manner, failed to monitor, assess, or document the wound, and did not complete or document required diabetic foot checks. Wound care orders from podiatry were not carried out, and the wound was not measured or assessed as required. The resident's care plan was not updated to reflect the infection, wound, or subsequent amputation of all five toes on the right foot. A third resident developed a vascular ulcer on the right leg. Staff failed to transcribe wound and antibiotic orders to the Treatment Administration Record (TAR), resulting in missed treatments and a four-day delay in antibiotic administration. Weekly wound assessments and measurements were not completed, and a person-centered care plan for the vascular ulcer was not developed. The ulcer deteriorated and became infected, leading to hospitalization for cellulitis and intravenous antibiotics. Across these cases, the facility did not complete RN assessments with changes in condition, did not follow provider orders, and failed to document and implement required care and monitoring, resulting in immediate jeopardy.
Failure to Provide Adequate Supervision and Safe Environment for Residents
Penalty
Summary
The facility failed to ensure that two residents were provided with adequate supervision and a safe environment, resulting in accident hazards and actual harm to one resident. One resident with multiple complex diagnoses, including Parkinson's disease, traumatic brain injury, epilepsy, and mobility impairment, was identified as being at high risk for falls and required staff assistance for transfers and toileting. Despite a physical therapist's documented recommendation for 1:1 supervision due to repeated falls and a history of seizures, the facility did not implement this intervention or increase supervision. The resident experienced multiple unwitnessed falls, including one that resulted in a hip fracture while self-transferring from a wheelchair to bed. Documentation showed that the care plan was reviewed after each fall, but no new or enhanced interventions were put in place, and there was no evidence of staff education following the injury. Interviews with staff and administration confirmed that 1:1 supervision was not provided, and there was no documentation explaining why the recommended intervention was not implemented. Another deficiency was observed regarding the charging of a power wheelchair. A resident with multiple medical conditions, including diabetes, muscle weakness, and mild cognitive impairment, was found charging their motorized wheelchair in their room, rather than in a designated charging area behind a fire-safe door. The facility administrator acknowledged that the wheelchair should not have been charged in the resident's room and that there was no policy or procedure in place for power wheelchair charging. The lack of a policy and the improper charging location created a potential accident hazard within the resident's environment. The facility's own policies and clinical guidelines require the assessment of fall risk, implementation of appropriate interventions, and maintenance of a safe environment free from hazards. In both cases, the facility did not follow through with necessary actions to prevent accidents, either by failing to implement recommended supervision for a high-risk resident or by not having procedures in place to ensure safe charging of power wheelchairs. These failures resulted in actual harm to one resident and the presence of accident hazards for another.
Failure to Date Mark Opened and Thawed Food Items in Dietary Services
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and sanitary environment for food storage, preparation, and distribution, as required by professional standards and facility policy. Specifically, food items such as milk, mandarin oranges, barbecue sauce, and magic cups were found to be opened or removed from their original packaging without being labeled with open or thaw dates. The facility's policy requires all opened or prepared food to be clearly marked with the date by which it should be consumed or discarded, and for the head cook or designee to check the refrigerator daily for expiring items. During interviews, the Dietary Manager acknowledged that magic cups should be labeled with thaw dates and all opened food or drink should have open dates, but was unable to confirm when the observed items had been opened or thawed. The Nursing Home Administrator and Director of Nursing also confirmed that food removed from manufacturer packaging and opened milk should be labeled with use by or open dates, and that magic cups require thaw dates. These lapses in date marking and labeling were observed to have the potential to affect all 41 residents in the facility.
Failure to Maintain Clean, Safe, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents. Observations included soiled linens, dirty towels, food, clothing, and various items scattered on the floors of several resident rooms. In one instance, a resident's bed had yellowish/brown stains on the sheets and pillowcase, and the floor was cluttered with food, personal items, and trash. Residents and their representatives voiced concerns about the cleanliness of their rooms and personal equipment, such as wheelchairs, which were observed to be dirty with dried food particles and stains. Interviews with staff revealed a lack of clarity regarding responsibility for cleaning certain items, particularly wheelchairs. Housekeeping staff, CNAs, and other personnel were unsure about who was responsible for cleaning wheelchairs or how often this should occur. Some staff recalled that there was previously a schedule for wheelchair cleaning, but it was no longer in use, and no one could confirm the current process. This lack of a defined cleaning protocol contributed to the ongoing issues with unclean equipment and resident environments. Additional environmental deficiencies were noted, such as water stains and a cut-out section in a resident's ceiling due to a leaking roof, cobwebs above beds, and various debris including straw wrappers, crumbs, and personal items on the floors of multiple rooms. Maintenance issues, such as unresolved roof leaks and water damage, were acknowledged by facility leadership but remained unaddressed at the time of the survey. Residents with varying levels of cognitive impairment and complex medical conditions were affected by these deficiencies, with several expressing dissatisfaction with the cleanliness and upkeep of their living spaces.
Failure to Assess and Document Bed Rail Safety and Alternatives
Penalty
Summary
The facility failed to ensure that alternatives were attempted prior to the installation and use of bed rails for multiple residents. For six residents reviewed, there was no documentation that alternative interventions were tried before bed rails were installed. Additionally, the facility did not complete or document required assessments for the risk of entrapment, particularly when bed rails were used in combination with air mattresses, which is known to increase entrapment risk. There was also a lack of evidence that the risks and benefits of bed rail use were reviewed with residents or their representatives, and informed consent was not obtained or documented. For several residents, including those with significant medical conditions such as Parkinson's Disease, Multiple Sclerosis, morbid obesity, and cancer, the facility did not perform or document safety/gap tests between the mattress and bed rails. Comprehensive care plans and physician orders indicated the use of bed rails and air mattresses, but there was no evidence of updated bed rail assessments, ongoing monitoring, or audits of bed rails. Residents and family members reported not receiving education or information about the risks and benefits of bed rail use, and there was no written proof of consent in the medical records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibilities for assessing entrapment risk, performing gap measurements, and maintaining documentation. The maintenance director and DON each believed the other was responsible for certain aspects of bed rail safety and assessment. There was no documentation of routine maintenance or audits of bed rails, and staff could not provide evidence of completed assessments or education provided to residents or families. The facility's own policy and FDA recommendations regarding bed rail safety and assessment were not followed, resulting in multiple deficiencies related to the safe use of bed rails.
Failure to Serve Food and Drink at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink served to residents were palatable and maintained at safe, appetizing temperatures, as required by facility policy and professional food safety standards. During surveyor observations, two test trays were served with milk at temperatures above the recommended maximum of 41°F, specifically at 53.2°F and 48°F, which placed the milk in the temperature danger zone. The milk was also noted to taste warm. The food items were served after all other trays had been distributed, and while plates were covered, no plate warmers or ice were used to maintain appropriate temperatures for hot or cold items. Interviews with the Dietary Manager revealed a misunderstanding of the correct temperature range for cold foods, as she stated that cold foods should be served between 40°F and 55°F, rather than the required 41°F or less. The facility's own policies referenced the need to keep refrigerated, ready-to-eat, time/temperature control for safety (TCS) foods at 41°F or less, and to distribute and serve foods in a manner that maintains proper temperatures and prevents contamination. Despite these policies, the observed practices did not align with the stated requirements, resulting in the deficiency.
Failure to Document and Resolve Resident Grievance Regarding Missing Personal Item
Penalty
Summary
A resident with multiple complex medical conditions, including muscle wasting, neoplasm-related pain, diabetes, morbid obesity, immunodeficiency, chronic respiratory failure, cancer, and acute kidney failure, reported a missing gray scrub top to laundry staff. The resident, who was cognitively intact, expressed frustration about the missing item and stated she had reported it to a laundry aide approximately two months prior. The laundry aide confirmed receiving the complaint but did not document the grievance, report it to a supervisor, or escalate it to the Grievance Official as required by facility policy. The aide also indicated there was no log for lost or missing items and was unsure of the process for unresolved missing items. Further interviews revealed that the Housekeeping/Laundry Manager only became aware of the missing item after being informed by the laundry aide a week prior to the survey. The manager described an informal process of searching for the item and, if not found, eventually notifying medical records to replace it, but did not mention any documentation or formal grievance filing. The Nursing Home Administrator stated that staff are expected to report missing items to the Social Worker, search for the item, complete a grievance form, and replace the item if not found. However, in this case, the facility failed to document, investigate, or resolve the grievance in accordance with its own grievance policy.
Failure to Complete Required Skin Assessments After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, after two separate hospitalizations, there was no documentation that a full body skin assessment was completed upon the resident's return, as required by the facility's own policy. The policy mandates that a licensed or registered nurse perform a full body skin assessment upon admission or readmission, daily for three days, and weekly thereafter. Despite this, there were no skin or wound assessments documented for the dates the resident returned from the hospital. The resident involved had multiple risk factors, including type 2 diabetes with polyneuropathy, chronic venous hypertension with ulcer, and a history of pressure ulcers. The resident's Braden Scale scores fluctuated between high and mild risk for pressure ulcers. Progress notes and wound visit reports confirm that wound assessments were not performed or documented on the days the resident returned from the hospital, and staff interviews confirmed that assessments were expected but not completed. Direct observation of the resident's wound revealed significant changes in the wound's size and appearance, further underscoring the lack of timely assessment.
Failure to Provide Routine Diabetic Foot Checks
Penalty
Summary
The facility failed to provide routine diabetic foot checks as required by physician orders and facility policy for two residents with diabetes. For one resident with type 2 diabetes, diabetic polyneuropathy, and a history of pressure ulcers, the care plan and physician orders specified daily foot checks at bedtime. However, documentation showed that foot checks were not completed or signed off on several dates, and there was no documentation of foot checks prior to the initiation of the order. Interviews with nursing staff and the interim director of nursing confirmed that if the checks were not documented, they were not done, and that nightly foot checks were expected. For another resident with diabetes and a recent ankle fracture, physician orders and the treatment administration record also required nightly diabetic foot checks. Review of the records revealed multiple dates across several months where foot checks were not completed. An LPN interviewed could not recall specific details about the resident's foot checks and admitted that checks were sometimes rushed due to the resident's agitation. Additionally, a dressing placed by podiatry remained unchanged for several days, despite documentation indicating that foot checks had been completed. The interim director of nursing confirmed that foot checks should be completed and documented as ordered, and that any abnormalities should be recorded in a progress note.
Delay in Initiation of Prescribed Antibiotic for Cellulitis
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from significant medication errors. The resident, who had a history of diabetes, a serious right ankle fracture, and dementia, was admitted to the facility and later sent to the emergency room with complaints of abdominal pain and right third toe redness and swelling. The ER diagnosed early cellulitis of the right third toe and prescribed an antibiotic (Keflex 500 mg four times daily for 7 days). The ER instructions included prompt initiation of the antibiotic. Despite these instructions, the facility delayed entering the antibiotic order into the Medication Administration Record (MAR) until the day after the ER visit, and the first dose was not administered until two days after the ER visit. Interviews with facility staff confirmed that new orders are not always processed immediately, and the facility's own policy requires timely documentation and transcription of new medication orders. This delay resulted in the resident not receiving the prescribed antibiotic as promptly as required.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to implement and maintain its infection prevention and control program as required, specifically regarding Enhanced Barrier Precautions (EBP) for two residents. For one resident with an indwelling urinary catheter, two CNAs transferred the resident from a wheelchair to the bathroom using a sit-to-stand machine and assisted with personal care activities, including moving the catheter bag and removing clothing, without wearing gloves or gowns. Both CNAs acknowledged after the fact that they were aware of the EBP requirements and should have worn appropriate PPE during these high-contact care activities, as indicated by the signage and care plan. In a separate incident, a resident with multiple wounds, including a pressure ulcer and venous ulcers, was observed during a wound dressing change. The Interim DON removed the resident's bandage and border dressing without wearing a gown, only donning gloves after handling the resident's leg. The Interim DON initially stated that a gown was not required unless there was a positive wound culture or excessive drainage, which contradicted the facility's policy and the expectations confirmed by the Vice President of Clinical and the Nursing Home Administrator, both of whom stated that both gown and gloves are required for wound care under EBP.
Failure to Document and Resolve Grievances per Facility Policy
Penalty
Summary
The facility failed to document a thorough investigation and resolve grievances in accordance with its own grievance policy for a resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson's Disease, dementia, dysphagia, and moderate protein-calorie malnutrition. The resident's activated power of attorney (POA) voiced ongoing concerns about the resident's care, specifically regarding hydration, via email. Despite these concerns being communicated, the facility did not document the grievance, conduct a thorough investigation, or provide a written response as required by their policy. During the survey, facility leadership, including the current Nursing Home Administrator (NHA) and Director of Nursing (DON), were unable to produce documentation of grievances for the relevant period and indicated that the grievance binder was empty. The facility only provided grievances for the current month and could not account for previous months, despite the POA's documented concerns. The NHA acknowledged that the facility should have followed its grievance policy and that the POA's concerns should have been documented and addressed as a grievance.
Failure to Complete Thorough Abuse Investigations and Timely Reporting
Penalty
Summary
The facility failed to conduct thorough investigations and timely reporting in response to allegations of abuse involving multiple residents. In one instance, a resident with moderate cognitive impairment reported being verbally abused by another resident, who used derogatory language in the dining room. Although the facility separated the residents and obtained statements, there was no documentation that other residents were interviewed to determine if they were also affected, as required by facility policy. Additionally, the final investigation report was not submitted to the State Agency within the required five working days. In another case, a cognitively intact resident reported being verbally abused by a CNA, who called the resident a derogatory name. While psychosocial support was reportedly offered, there was no documentation that the resident was assessed for psychosocial harm, such as a trauma assessment or PHQ2-9, as described by the Social Services Director. The final investigation report for this incident was also not submitted within the required timeframe. A third incident involved a staff member allegedly making an inappropriate statement to a resident. The final report for this event was also not submitted within the five-day requirement. Interviews with facility leadership confirmed that assessments and timely reporting were expected but not completed as per policy and regulatory requirements. The lack of documentation and delayed reporting were consistent across the reviewed cases.
Failure to Ensure Resident Is Free from Significant Medication Errors
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including cancer, diabetes, morbid obesity, immunodeficiency, pathological fracture, secondary malignant neoplasms, acute kidney failure, depression, anxiety disorder, and muscle wasting, did not receive all prescribed medications as ordered by the physician during February and March. Specifically, the resident missed several doses of Anastrozole, a cancer medication, and Methadone, a pain medication, as evidenced by blank entries and unexplained codes on the Medication Administration Record (MAR). Interviews with nursing staff, including LPNs, an RN, and the Director of Nursing, revealed inconsistent documentation practices. Staff confirmed that blank boxes on the MAR typically indicate that a medication was not given, and a code of '7' should be accompanied by a nurse's note explaining the reason for non-administration. However, in multiple instances, there were no corresponding nurse's notes, and staff could not confirm whether the medications were administered or the reasons for omission. Staff also acknowledged that there had been issues with prior authorization for Methadone, which contributed to missed doses, and that PRN pain medications were offered as substitutes. The facility's policy requires immediate documentation of medication administration on the MAR, but this was not consistently followed. The lack of proper documentation and unexplained missed doses resulted in the resident not receiving all prescribed medications as ordered, constituting a significant medication error.
Resident's Right to Choose Physician Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the case of a resident who was unable to switch to a new primary care physician (PCP) due to the facility's extensive requirements. The resident, who was cognitively intact and had a history of secondary malignant neoplasm of bone, neoplasm-related pain, and type two diabetes mellitus, expressed dissatisfaction with the current facility physician and wished to change to a physician at an external clinic. Despite the resident's and family member's efforts to facilitate this change, the process was hindered by the facility's demands for extensive documentation from the new physician. The facility's policy supports residents' rights to choose their attending physician, provided the physician meets state and federal requirements. However, the facility's process for changing PCPs involved sending a lengthy form to the new physician, MD I, which included requests for personal and professional information that MD I found excessive and unnecessary. This form was not retained by the facility, and there was a lack of follow-up communication with MD I, who ultimately decided not to proceed with becoming the resident's PCP due to the prohibitive nature of the facility's requirements. Interviews with facility staff revealed a lack of clarity and documentation regarding the process for changing PCPs. The Social Service Director was unaware of the procedure, and the Director of Nursing, who was out sick, had not communicated with the new physician. The Scheduler attempted to follow up but did not document these efforts. As a result, the resident's request to change physicians was not fulfilled, and the facility's medical director continued as the resident's PCP, contrary to the resident's expressed wishes.
Failure to Protect Resident from Verbal Abuse by Housekeeper
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a housekeeper, which constitutes a deficiency in ensuring residents' rights to be free from abuse. The incident involved a resident with a traumatic brain injury, dementia, and diabetes mellitus, who was moderately cognitively impaired. The housekeeper engaged in a verbal altercation with the resident, using derogatory language and swearing at the resident in a confrontational manner. Despite the presence of other staff members, the situation was not adequately de-escalated, and the resident was not protected from the verbal abuse. The incident was reported by a Registered Nurse (RN) who documented that the housekeeper and the resident had a verbal disagreement, during which the housekeeper used offensive language towards the resident. The RN reported the incident to the Director of Nursing (DON) and sent the housekeeper home pending an investigation. A Med Tech (MT) who witnessed the incident attempted to intervene by calling the housekeeper's name but did not physically separate the housekeeper from the resident. The MT later confirmed that the housekeeper's behavior was abusive. Interviews conducted by the surveyor revealed that the staff did not take sufficient action to protect the resident during the incident. The DON confirmed that staff members are expected to protect residents from abuse and that the staff should have been educated on abuse prevention. The failure to intervene and protect the resident from verbal abuse highlights a deficiency in the facility's adherence to its policy on abuse prevention and resident protection.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse incidents involving two residents, R3 and R4, to the State Agency as required by their policy. The policy mandates that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported immediately to the administrator and other officials, including the State Survey Agency, within specified timeframes. In the case of R3, the facility became aware of an abuse allegation on January 23, 2025, at 11:36 PM, but did not report it to the State Agency until January 24, 2025, at 4:53 PM, which was beyond the required timeframe. R3, who has a diagnosis of schizoaffective disorder and moderate cognitive impairment, reported that a CNA threatened him with a gun. The Director of Nursing (DON B) received this information from R3's social worker but failed to document the time and date of this communication in R3's medical record. The facility's initial self-report was submitted on January 24, 2025, at 4:53 PM, indicating a delay in reporting the incident to the State Agency. In the case of R4, who is cognitively intact, the resident reported that a nurse threw an empty water cup at him. R4 informed the Nursing Home Administrator and DON B about the incident, but the facility did not report this allegation to the State Agency. DON B stated she was unaware of R4's abuse allegation and did not read the completed interviews regarding abuse, which included R4's response. As a result, the facility did not investigate or report this allegation, failing to adhere to their policy and state reporting requirements.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure a thorough investigation of abuse/exploitation for three residents. One resident, who was moderately cognitively impaired, was verbally abused by a staff member. The incident was reported, and the staff member was sent home pending investigation. However, the investigation was incomplete as there were no statements from key witnesses, and the staff was not adequately re-educated on handling abuse situations. Another resident, with moderate cognitive impairment, reported an allegation of abuse involving a CNA. The facility initiated an investigation, suspending the CNA and interviewing other residents and staff. However, the resident who made the allegation was not interviewed, which was acknowledged as a failure in the investigation process by the Director of Nursing. A third resident, who was cognitively intact, reported an incident where a nurse allegedly threw an empty water cup at them. This allegation was not investigated as the Director of Nursing was unaware of the report, despite it being documented in a resident interview. The facility did not follow its policy to investigate the allegation of abuse, leading to a deficiency in handling abuse reports.
Resident Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, was free from significant medication errors. R2, who has a diagnosis of secondary malignant neoplasm of bone, neoplasm-related pain, and type 2 diabetes mellitus, did not receive nine medications over two days and one medication on another day in January. These medications included critical treatments such as a cancer medication and pain medication, which were not administered as per the facility's policy on medication administration. The facility's policy requires that medication administration be charted immediately following administration, but R2's Medication Administration Record (MAR) showed blanks for the dates in question, indicating the medications were not given. Interviews with R2 revealed that there were times when medications were delayed due to pharmacy issues. The Licensed Practical Nurse (LPN) confirmed that a blank on the MAR indicates non-administration and that any missed medication should be documented in the progress notes, including the reason for non-administration and notification to the physician. Further interviews with the Chief Nursing Officer (CND) confirmed that the facility's expectation is for documentation to be made in the progress notes if a medication is not administered, including the reason and any actions taken, such as contacting the pharmacy or physician. However, no such documentation was found for the dates in question, indicating a lapse in following the facility's procedures and ensuring the resident's medication needs were met.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as R8, who had a history of dementia and expressed a desire to leave the facility. R8 was protectively placed at the facility with a guardian due to multiple diagnoses, including dementia with mood disturbance, respiratory failure, and anxiety. Despite R8's repeated statements about wanting to leave, the facility did not conduct a proper elopement assessment or update the care plan to address these risks. R8 was initially placed on 30-minute checks after expressing a desire to leave, but these checks were discontinued without a formal assessment or care plan update, based on the guardian's approval. On the day of the incident, R8 left the facility unnoticed by staff around 2:00 PM and was not located until approximately 7:30 PM by law enforcement. The facility was unaware of R8's absence until notified by the guardian at 4:30 PM. R8 managed to travel approximately 70 miles away from the facility, hitchhiking and using public transportation to reach a friend's house. The facility's failure to monitor R8 adequately and the lack of a comprehensive elopement risk assessment contributed to the resident's ability to leave the premises undetected. The facility's policy on elopement was not effectively implemented, as evidenced by the lack of an elopement assessment and the discontinuation of 30-minute checks without a formal evaluation. Staff were not aware of R8's departure, and the facility did not have measures in place to ensure R8's safety, such as a wander guard or supervised smoking times, until after the incident occurred. This oversight created a reasonable likelihood of serious harm, leading to a finding of immediate jeopardy.
Removal Plan
- An initial Elopement Drill was conducted to ensure all residents were accounted for at the facility.
- Elopement drills immediately conducted on all three shifts.
- Elopement drills now completed weekly and documented.
- R8 vitals and skin check was completed.
- R8's wander guard placement.
- R8 Elopement and Smoking assessments were completed.
- R8 now has supervised designated smoking times.
- R8 is on 15-minute checks and checks are documented.
- R8's care plan has been updated to reflect plan of care.
- All staff educated: R8's risk for elopement, elopement policy, elopement drills, and behaviors to watch for in residents.
- Facility now has a check in/check out binder for residents.
- Residents who are able to safely go out on their own have signed and reviewed agreement form.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting four out of six sampled residents. One resident, R5, was given Milk of Magnesia instead of the prescribed Magnesium Citrate, resulting in an overdose and subsequent hospitalization. The error occurred when the medication aide assured the resident that the incorrect medication was correct, leading to the resident consuming an excessive amount of Milk of Magnesia. Another resident, R7, did not receive prescribed cancer medications, Anastrozole and Ribociclib, on several occasions in November. The Medication Administration Record (MAR) was left blank for these dates, indicating that the medications were not administered. Interviews with the facility's staff confirmed that a blank MAR signifies a missed medication administration, which is considered a medication error. Resident R8 did not receive Suboxone as ordered for a significant period due to an insurance authorization issue. Despite the facility's responsibility to facilitate the delivery of medications, there was no documentation of follow-up with the physician to resolve the issue. Additionally, R3 did not receive prescribed amphetamine-dextroamphet medications for several days after admission due to a delay in obtaining the medication from the pharmacy. The facility's Director of Nursing acknowledged that the medications should have been administered per physician orders and that the facility is responsible for ensuring residents receive their prescribed medications.
Deficiency in Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable and maintained at safe and appetizing temperatures. This deficiency was identified during a surveyor's observation, interview, and record review, affecting one of three halls and one test tray. The facility's policy, dated 10/1/22, mandates that food be stored, prepared, distributed, and served according to professional standards for food service safety, with specific temperature requirements for hot and cold foods. However, during the survey, a test tray revealed that hot foods were served at temperatures below the required levels, and a cold beverage was served at a temperature above the safe limit. On the specified date, the surveyor received a meal tray for the 200-hall and measured the temperatures of the food items. The hot roast beef sandwich, peas, and tater tots were all served at temperatures below the required 165°F and 135°F, respectively. Additionally, the juice was served at 64.4°F, exceeding the maximum safe temperature of 41°F for cold beverages. The Dietary Manager (DM N) acknowledged the discrepancies in food temperatures and confirmed that the meal trays were expected to be delivered at the correct temperatures as per the facility's policy.
Failure to Protect Residents from Exploitative Actions by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R1, from abuse and exploitation by a Certified Nursing Assistant (CNA). CNA C took humiliating and exploitative pictures of R1 and other unidentified residents without their knowledge or consent. These pictures were then shown to other staff members. The facility's policy on abuse, neglect, and exploitation clearly prohibits such actions, defining mental abuse to include humiliation and exploitation facilitated through the use of technology. Despite this, CNA C took pictures of residents in compromising situations, such as a resident's outer thigh on top of a wet brief, and shared them with colleagues. R1, who was admitted to the facility with severe cognitive impairment, was one of the residents affected by this incident. Her medical conditions included idiopathic normal pressure hydrocephalus, depression, and Alzheimer's disease. The incident was reported by another CNA, who misunderstood the content of the photos as a sexual assault. However, the pictures did not include any genitalia but did show parts of residents' bodies in a demeaning context. The facility's staff, including the Director of Nursing (DON), were aware of the incident, but there was a lack of consensus on whether the actions constituted abuse. Interviews with various staff members revealed that some were aware of the inappropriate picture-taking but did not report it immediately. The facility's policy was not followed, as staff were not supposed to take pictures of residents, and there was no documentation of the incident in R1's medical record. Additionally, the facility did not complete facility-wide education on abuse prevention, identification, and reporting, leaving some staff members uninformed about the incident and the facility's policies.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by their policy. The policy mandates that allegations involving abuse must be reported to the Nursing Home Administrator (NHA) and the State Agency within two hours. However, several staff members were aware of an incident involving inappropriate photographs taken by a Certified Nursing Assistant (CNA) of residents and their rooms, but did not report it within the required timeframes. The incident involved a CNA who took photographs of a resident's peritoneal area and other residents while they slept, which were then shown to other staff members. Despite being aware of the situation, staff members, including another CNA and a Registered Nurse (RN), failed to report the incident to the NHA or the State Agency promptly. The RN did notify the Director of Nursing (DON) the following day, but this was outside the required reporting timeframe. The facility's policy on abuse, neglect, and exploitation was not followed, as staff did not recognize the act of taking photographs without consent as abuse or a violation of residents' rights. The facility's failure to report the incident in a timely manner was compounded by the fact that some staff members did not consider the act of taking photographs as abuse. The DON and other staff members were aware of the policy prohibiting cell phones in resident care areas, yet the policy was not enforced effectively. The Chief of Police was informed but did not conduct a law enforcement investigation, as the facility indicated they would handle it internally. The facility's lack of immediate reporting and recognition of the incident as abuse led to a deficiency in adhering to regulatory requirements.
Inadequate Investigation of Alleged Abuse/Exploitation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of abuse/exploitation involving a Certified Nursing Assistant (CNA) and a resident. The incident involved a CNA taking photographs of residents without their consent, which is a potential violation of the facility's policy on abuse, neglect, and exploitation. The policy explicitly prohibits taking demeaning or humiliating photographs of residents, regardless of consent or cognitive status. Despite this, the facility did not ask residents or staff specific questions related to the taking of inappropriate pictures during their investigation. The incident came to light when a CNA reported that another CNA had taken photos of a resident's peritoneal area and other compromising situations, such as a resident with chips on their neck and a soiled brief. The CNA who took the photos claimed they were intended to document poor care for management, believing that as long as no faces or private areas were shown, it was permissible. However, the facility's Director of Nursing (DON) acknowledged that the staff did not adhere to the policy prohibiting cell phones in resident care areas and taking pictures of residents. The facility's investigation was incomplete as it did not include questions about inappropriate picture-taking in interviews with residents and staff. The surveyor noted that the facility's documentation of the investigation lacked thoroughness, as it did not address whether staff or residents had witnessed or experienced the taking of dehumanizing pictures. This oversight indicates a failure to follow the facility's policy on conducting a comprehensive investigation into allegations of abuse, neglect, and exploitation.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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