Rock River Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Atkinson, Wisconsin.
- Location
- 430 Wilcox St, Fort Atkinson, Wisconsin 53538
- CMS Provider Number
- 525262
- Inspections on file
- 37
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Rock River Nursing & Rehab during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple psychiatric and neurologic diagnoses, including Alzheimer’s disease and Parkinson’s disease, reported being hit by staff and having a bloody nose. Facility policy required that all abuse allegations be reported to the state agency within two hours, but the incident was reported more than five hours after the allegation. The previous ED acknowledged the delay, stating he followed direction from a corporate leader, while the DON and current ED both affirmed that abuse allegations are required to be reported immediately and within the two-hour timeframe.
A resident reported two missing Apple laptops, but the facility did not thoroughly investigate the allegation or provide staff education on misappropriation as required by policy. The resident, who was cognitively intact, expressed dissatisfaction with the lack of resolution, and staff interviews confirmed no follow-up actions or training were conducted.
Four residents were not properly supervised or provided with necessary safety interventions while smoking, resulting in unsafe behaviors such as retrieving and smoking discarded cigarette butts, accumulating burn holes in clothing, and using non-fire-rated containers for cigarette disposal. Staff interviews revealed inconsistent monitoring and incomplete documentation of residents' smoking safety assessments, with some staff unaware of required safety equipment or procedures.
Two non-nursing staff members, a cook and a housekeeping staff member, did not receive the required behavioral health training as determined by the facility assessment. Review of in-service training records and interviews with facility leadership confirmed the absence of documentation for this training.
A resident did not receive the medically-related social services needed to achieve the highest possible quality of life, as required. This failure was identified through surveyor findings that indicated the necessary support services were not provided.
A cook did not receive required annual training on resident rights and facility responsibilities after initial orientation. The administrator confirmed the absence of documentation for this training and acknowledged responsibility for ensuring non-nursing staff compliance.
A non-nursing staff member did not receive required annual training on abuse, neglect, exploitation, and dementia care after initial orientation. The facility was unable to provide documentation of annual in-service training for this staff member, and the Administrator confirmed responsibility for ensuring such training is completed.
A cook did not receive required annual QAPI training after initial orientation, as confirmed by review of in-service records and administrator interview. The administrator acknowledged responsibility for ensuring non-nursing staff receive mandatory training.
The facility did not ensure that daily nurse staffing postings were accurate or clearly presented, with multiple discrepancies found between posted census information and actual staffing schedules. Inconsistencies included incorrect counts of CNAs, inclusion of trainees in staffing numbers, and unclear documentation, as confirmed by interviews with the scheduler and administrator.
Two residents did not receive care in accordance with professional standards and their care plans. One resident with depression and recent surgery experienced significant weight loss, poor intake, and depressive symptoms without timely provider notification or appropriate interventions, leading to hospitalization for severe complications. Another resident who suffered a head injury from a fall did not receive required neurological checks. The facility failed to follow its own policies for care planning, monitoring, and communication.
Two residents at risk for pressure injuries did not receive timely or consistent implementation of physician-ordered interventions such as floating heels and use of heel boots, as documented in the TAR and care plans. One resident developed a deep tissue injury (DTI) to the heel with inconsistent wound documentation and delayed use of preventive devices, while another developed a Stage 1 pressure injury that progressed to a DTI, with preventive measures only implemented after the injury was found. Both cases showed a lack of adherence to facility policy on pressure injury prevention and documentation.
Multiple residents with cognitive and physical impairments experienced falls due to inadequate supervision, missing or improperly implemented safety interventions, and incomplete investigations. Required care plan interventions such as low bed positioning, fall mats, and accessible call lights were not consistently in place, and post-fall investigations lacked staff statements, root cause analysis, and documentation of neurological checks after injuries.
The facility failed to maintain adequate nursing and support staff on multiple shifts, resulting in one LPN being left alone for 30 residents and only one CNA covering night shifts for several hours. Residents required high levels of care, including Hoyer lifts and two-person transfers, but staffing reductions led to delayed meals, incomplete documentation, and staff dissatisfaction. Leadership and staff acknowledged the unsafe conditions and the inability to meet residents' needs due to these staffing changes.
The facility did not maintain an effective infection prevention and control program, as shown by outdated water management documentation, incomplete infection surveillance records, and failure to follow proper infection control practices during medication administration. A DON administered eye drops to a resident without wearing gloves, and infection surveillance reports lacked details on organisms and corrective actions.
The facility did not have a designated, qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP). The DON was acting as the IP without having completed the required specialized infection control training, and the ADON was still in training. The facility assessment did not include the IP role or specify required hours, and neither staff member had the necessary qualifications as outlined in facility policy.
The facility did not provide a covered or weather-protected designated smoking area as required by its policy, resulting in residents who smoke—some with mobility limitations—choosing to smoke under the entrance overhang or in front of the entrance instead. The NHA was unaware of the weather protection requirement for the smoking area.
A resident with severe cognitive impairment and a history of falls was not provided with ongoing re-evaluation for the use of a seatbelt as a physical restraint. The facility only completed an initial assessment and failed to document any further comprehensive reassessment, despite policy requirements and a physician order to remove the seatbelt during meals. Staff continued to use the seatbelt without updated evaluation or care plan documentation.
A resident with intact cognition alleged that a CNA hit them on the head. The facility completed an internal investigation and reported the incident to the state agency, but failed to notify law enforcement as required by policy. Interviews confirmed that law enforcement was not contacted at the time of the allegation, and the administrator cited lack of evidence as the reason for not reporting.
Two residents were not properly offered or documented for influenza and pneumococcal vaccinations as required by facility policy. One resident with diabetes and respiratory conditions had no record of being offered or receiving a pneumococcal vaccine, and another with morbid obesity and pneumonia had no documentation of being offered or receiving the influenza vaccine for the current season. Facility records and interviews confirmed the lack of required documentation and assessment.
A resident with moderate cognitive impairment and an activated HCPOA was not given the opportunity to participate in care planning, as neither the resident nor the HCPOA were formally invited to quarterly care conferences, and the facility could not provide documentation that these conferences occurred or that invitations were extended.
A resident admitted with a recent leg fracture and major depressive disorder did not have a baseline care plan developed within 48 hours, as required by facility policy. Staff interviews revealed confusion about responsibility for initiating the care plan, and the necessary person-centered interventions for the resident's medical and psychological needs were not documented.
Three residents prescribed Eliquis for conditions such as embolism, thrombosis, and heart failure did not have documented monitoring for adverse reactions or side effects, despite care plans requiring such monitoring. Review of MARs and TARs showed no evidence of medication monitoring, and interviews with the DON confirmed that monitoring should occur every shift. Facility leadership was unable to provide additional documentation to show that monitoring was performed.
A resident with Major Depressive Disorder was prescribed Fluoxetine without a corresponding care plan or documented side effect monitoring. Staff interviews revealed confusion about responsibility for care planning, and record review confirmed the absence of required documentation for both the resident's depression and psychotropic medication use.
A resident experienced multiple seizures without prior history, and the facility failed to assess the cause, develop a care plan, or administer prescribed medications timely. Other residents also faced care deficiencies, including improper medication administration and lack of necessary assessments. The facility's failure to adhere to professional standards led to Immediate Jeopardy.
A resident with a history of multiple medical conditions experienced seizures due to the facility's failure to provide timely pharmaceutical services. Despite physician orders for medications like Lorazepam and Levetiracetam, the facility did not ensure these were picked up and administered promptly, leading to hospitalization and death. Additionally, other residents experienced delayed medication administration, indicating systemic issues in the facility's medication management.
The facility did not complete performance reviews for four CNAs, potentially affecting all 35 residents. The CNAs, hired between 2001 and 2023, lacked evaluations for specified periods. The DON confirmed yearly evaluations are required but could not provide them. The Nursing Home Administrator and DON were informed, but no explanation was given for the oversight.
The facility's governing body failed to maintain the HVAC system, resulting in inadequate heating in the north hallway. Despite efforts to address the issue, temperatures remained below the comfortable range, affecting residents who refused to relocate. The Nursing Home Administrator was initially unaware of the problem, and the facility struggled to secure timely HVAC service due to a canceled contractor agreement.
The facility failed to provide the required annual Effective Communication training to five CNAs, as revealed by a survey. Despite the facility's policy mandating this training, records for CNAs hired on various dates showed no evidence of completion. The DON acknowledged the absence of documentation and suggested records might be offsite, but no further evidence was provided.
The facility did not ensure that five CNAs received the mandatory annual QAPI training, as required by federal regulations. Despite requests for documentation, the facility could not provide evidence of QAPI training for these CNAs, potentially affecting all 35 residents. The Director of Nursing acknowledged the absence of records, and no further documentation was provided to confirm the completion of the required training.
The facility did not ensure that staff received the required annual Compliance and Ethics training, affecting all 35 residents. Five CNAs were found to have not received the necessary training, as confirmed by the DON. Despite requests for additional information, no documentation was provided to demonstrate compliance with the training requirements.
The facility failed to provide required behavioral health training to five CNAs, as mandated by their policy and federal regulations. Despite requests for documentation, the DON could not initially provide evidence of training, and subsequent submissions confirmed the absence of such training. This deficiency affects the facility's ability to adequately care for residents with mental, psychosocial, or substance use disorders.
A malfunctioning heating unit in a facility led to temperatures below the required range, affecting residents' comfort. Despite efforts to repair the unit and offer room changes, several residents chose to stay in their rooms, using extra blankets and clothing to cope with the cold. The facility's response was delayed, and the issue persisted, impacting the residents' right to a comfortable environment.
The facility failed to notify physicians and resident representatives of changes in treatment for two residents, leading to a deficiency. One resident's guardian was not informed of new medical orders, and medications were administered late without notifying the physician. Another resident experienced late medication administration without physician notification. Staff interviews confirmed the requirement to notify and document, but this was not done.
A facility failed to thoroughly investigate a resident-to-resident altercation involving two residents, where one resident kicked another in the shin. The incident report lacked statements from other residents and comprehensive staff statements about the residents' behaviors prior to the altercation. Additionally, no education was provided to staff to prevent future incidents. Interviews with staff confirmed the absence of additional statements and education following the incident.
A resident with multiple diagnoses, including morbid obesity, fell during a bed bath when the bed moved away from the wall. The care plan required two staff members for assistance, but only one CNA was present, and the resident was rolled away from the staff member, leading to the fall. The facility's investigation noted the bed position as a factor but did not address the failure to follow the care plan.
An LPN hired at the facility did not complete the required competency assessment after being hired, as revealed during a survey. An anonymous complainant reported that new employees were not receiving proper training and orientation. The BOM/HR acknowledged the need for a better orientation process and could not provide the competency for the LPN, although competencies for two CNAs were located.
A facility failed to maintain a medication error rate below 5%, resulting in a rate of 5.88% due to two errors. One resident's Lispro insulin bottle was not dated, leading to uncertainty about its expiration. Another resident received Metoprolol Succinate ER without prior vital sign checks, contrary to physician orders. These oversights contributed to the elevated error rate.
A facility failed to maintain accurate medical records for a resident, with multiple blank entries in the Treatment Administration Records over three months. These blanks were not explained, leaving it unclear if treatments were completed, refused, or undocumented. The resident required diabetic foot checks and wound care, but the facility did not adhere to its policy of documenting medication administration and refusals.
The facility failed to provide two CNAs with the required annual training on Resident Rights and facility responsibilities, as mandated by policy. This deficiency was identified through interviews and record reviews, revealing that the CNAs did not receive the training within the specified timeframe based on their hire dates, potentially affecting all 35 residents.
A facility failed to provide a CNA with the required annual training on abuse, neglect, and dementia care, as mandated by regulations. Documentation showed that CNA-H did not receive dementia training within the specified timeframe from their hire date. The DON was unable to initially provide evidence of the required training for several CNAs, and later documentation confirmed the deficiency. This oversight had the potential to affect all 35 residents in the facility.
The facility failed to provide required annual Infection Control training to two CNAs, CNA-H and CNA-DD, as mandated by their policy. CNA-H did not receive any training within the specified timeframe, and CNA-DD's last training was outside the required period. The Director of Nursing could not provide documentation of the training, indicating a lapse in compliance with infection control training requirements.
The facility failed to maintain an effective pest control program, leading to a significant fly problem throughout the building. Observations noted flies in resident rooms, hallways, and common areas. Residents and staff confirmed the issue, with some residents taking personal measures to manage the nuisance. The facility did not have pest control services in June and July, contributing to the ongoing problem.
The facility failed to maintain a clean and homelike environment, as observed in a resident's room and the facility's grounds. A shared bathroom had dried brown material suspected to be BM on the wall and a sticky floor, while the resident's room had paint scrapings and plaster gouges. The resident, who is severely cognitively impaired and incontinent, does not use the bathroom due to its unclean state. Additionally, the facility grounds were littered with various items, and there was confusion over who was responsible for cleaning these areas.
A facility failed to provide sufficient nursing staff, leading to delayed responses to call lights and unmet care needs. A CNA was reassigned to pass medications, leaving residents without adequate assistance. Multiple residents reported long wait times for help, with one resident waiting over two hours for toileting assistance. Surveyors observed several call lights going unanswered, highlighting a systemic staffing issue.
A CNA was observed administering medications to residents without the necessary qualifications or recent training, as required by the facility's policy. The CNA had not passed medications for two years and reported being pulled from her aide duties by an RN to perform this task. The CNA's employee file lacked evidence of the required training or certification, indicating a deficiency in the facility's staffing and training practices.
A long-term care facility failed to provide adequate pharmaceutical services, resulting in residents not receiving medications as prescribed. On one unit, morning medications were delayed, and a CNA unfamiliar with medication administration was tasked with passing meds, leading to further delays. A resident's pain medication was administered late due to a misunderstanding of the physician's order. Additionally, a nurse returning to cover a shift did not administer medications due to uncertainty about previous administrations, resulting in missed doses for several residents.
Two residents were not informed of changes to their medication regimens, violating their rights to participate in treatment decisions. One resident was administered a psychotropic drug without consent, while another was unaware of changes to their Oxycodone dosage. The facility failed to communicate these changes, as required by policy.
A resident with multiple health conditions was not included in the development and implementation of their person-centered care plan. Despite being cognitively intact, the resident had not participated in a care conference since admission, contrary to the facility's policy requiring quarterly conferences. Facility staff could not provide documentation of the resident's involvement in care planning.
A resident with multiple health conditions had their air conditioning unit removed from their room without prior notice or explanation while they were at the emergency room. Upon return, the resident had to purchase a personal air conditioner to maintain comfort. The facility's maintenance director confirmed the installation of the personal unit, and the nursing home administrator stated the original unit was needed elsewhere. Observations showed other air conditioners in common areas, some not in use.
Two residents were moved to different rooms without prior written notice or explanation, causing distress and dissatisfaction. The facility's policy requires advance notice for room changes, but this was not followed. The Nursing Home Administrator and Director of Social Services acknowledged the oversight, citing reasons like census management and payer status changes.
Failure to Timely Report Allegation of Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse within the required two-hour timeframe to the state survey agency. Facility policy titled “Abuse, Neglect, and Exploitation,” dated 10/01/2022, required that all alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours after the allegation is made. The resident involved had been admitted with a history of Parkinson’s disease, depression, anxiety disorder, somatization disorder, personality disorder, and Alzheimer’s disease, and an admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The resident’s care plan documented behavioral symptoms such as verbal aggression, combativeness, throwing objects, refusing care and therapy, calling 911 for nonemergent needs, accusatory behavior toward staff, and delusions. On the date of the incident, a Misconduct Incident Report documented that at approximately 3:30 PM the resident reported being hit by staff and having a bloody nose. The facility submitted this report to the state survey agency at 9:16 PM the same day, more than five hours after the allegation was made, contrary to the policy requirement for reporting within two hours. In an interview, the previous Executive Director acknowledged not reporting the allegation within two hours and stated he was following direction from the Corporate Lead. The DON stated that any abuse allegation should be reported to the ED immediately and then to the state survey agency within two hours, and confirmed that the report related to this allegation was not submitted timely, without knowing the reason. The current ED also stated that all abuse allegations must be reported to her immediately and then to the state survey agency within two hours.
Failure to Investigate and Educate Following Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of property involving a resident who reported two missing Apple laptops. The resident, who was cognitively intact and able to communicate clearly, reported the missing items to the Nursing Home Administrator (NHA), who searched the resident's room with permission but did not locate the laptops. Interviews with staff revealed that one staff member had moved the resident to a new room but did not see the laptops, while another recalled seeing the laptops in a box months earlier. Seventeen other residents were interviewed and denied any knowledge or involvement in the incident. Despite the report, there was no documented follow-up to resolve the missing property issue, and the resident expressed dissatisfaction with the lack of resolution and communication regarding the missing laptops. Additionally, the facility did not provide staff education or training related to misappropriation of property following the incident, as required by facility policy. The NHA acknowledged that no staff education had been conducted and was unable to explain the delay in offering the resident a lock for valuables. There was also no evidence that the value of the missing laptops was addressed or replaced. The lack of thorough investigation and absence of staff education represent a failure to implement the facility's policy on protecting residents from misappropriation and ensuring appropriate follow-up after such allegations.
Failure to Supervise and Safeguard Residents During Smoking Activities
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for four residents who smoked, resulting in a finding of Immediate Jeopardy. Surveyors observed multiple instances where residents were not properly assessed for their ability to smoke safely, and care plan interventions were either missing or not implemented. Residents were seen retrieving and smoking discarded cigarette butts from receptacles, accumulating cigarette ashes and burn holes on their clothing, and using unsafe, non-fire-rated containers for cigarette disposal. Staff interviews revealed a lack of consistent monitoring and supervision in the designated smoking areas, with some staff unaware of the need for supervision or the presence of safety equipment such as smoking aprons. One resident with moderate cognitive impairment and a history of psychiatric and neurological diagnoses was observed with cigarette ashes on his clothing, taking cigarette butts from receptacles, and attempting to light and share them with others. Another resident, cognitively intact but with significant medical conditions including COPD and atrial fibrillation, was seen using a wooden clothespin to hold cigarettes and a plastic car ashtray, which is not fire-rated, for disposal. A third resident, also cognitively intact but with hemiplegia and visual impairment, was observed with burn holes in her shirt and reported difficulty using a lighter due to her physical limitations. Her care plan indicated the use of a smoking apron, but it was not available during the initial survey observations. A fourth resident, with a history of dementia and developmental disorder, was also seen retrieving and smoking cigarette butts from receptacles. Staff interviews indicated a lack of clarity regarding procedures for assessing residents' smoking safety, implementing care plan interventions, and monitoring residents while smoking. Several staff members stated they did not observe residents while smoking, and some were unaware of the presence or use of smoking aprons. Documentation in residents' records was incomplete, with smoking assessments lacking marked observations or care planning interventions. The facility's policies required assessment and documentation of residents' ability to smoke safely, but these were not consistently followed, leading to unsafe smoking practices and the accumulation of burn-related injuries and hazards.
Removal Plan
- Assessed all residents who smoke to evaluate their physical and cognitive capabilities.
- Identified residents who require supervision or adaptive equipment during smoking.
- Updated each resident's care plan to reflect safe smoking.
Non-Nursing Staff Lacked Required Behavioral Health Training
Penalty
Summary
The facility failed to ensure that two non-nursing staff members, specifically a cook and a housekeeping staff member, received the required behavioral health training as determined by the facility assessment. The surveyor requested in-service training records for a sample of nursing and non-nursing staff, including the cook and housekeeping staff. Upon review of the provided in-service training documentation, the surveyor was unable to locate any record indicating that either the cook or the housekeeping staff member had received behavioral health training. When questioned, the corporate representative stated that the administrator is responsible for ensuring non-nursing staff receive their required training. The administrator confirmed that there was no available documentation of behavioral health training for the two non-nursing staff members. The deficiency was identified through interviews and record reviews, with no evidence provided to demonstrate compliance with the behavioral health training requirement for these staff members.
Failure to Provide Medically-Related Social Services
Penalty
Summary
The facility failed to provide medically-related social services necessary to help each resident achieve the highest possible quality of life. This deficiency was identified based on observations and findings that the required social services were not delivered to residents as needed, impacting their ability to attain or maintain their optimal well-being.
Non-Nursing Staff Missed Annual Resident Rights Training
Penalty
Summary
The facility failed to ensure that all non-nursing staff received annual training on resident rights and facility responsibilities, as required. Specifically, a cook hired on 10/2/23 received the initial training on the date of hire but did not receive subsequent annual training. During the survey, the surveyor requested in-service training records for selected staff, including the cook, and found no evidence of annual training after the initial session. When questioned, the administrator confirmed that there was no documentation of the required annual training for the cook and acknowledged responsibility for ensuring non-nursing staff receive this training.
Failure to Provide Annual Abuse, Neglect, Exploitation, and Dementia Training to Non-Nursing Staff
Penalty
Summary
The facility failed to ensure that one of two non-nursing staff members selected at random received required annual training on abuse, neglect, exploitation, and dementia care. Specifically, Cook-L was hired on 10/2/23 and received initial training on abuse, neglect, exploitation, and dementia management on the date of hire, but there was no evidence of any subsequent annual training provided. During the survey, the surveyor requested in-service training records for selected staff and found that Cook-L had not received the required annual training after the initial session. When questioned, the corporate representative and the Nursing Home Administrator confirmed that there was no documentation of annual training for Cook-L, and the Administrator acknowledged responsibility for ensuring non-nursing staff receive required training.
Failure to Provide Annual QAPI Training to Non-Nursing Staff
Penalty
Summary
The facility failed to ensure that all non-nursing staff received annual training on the Quality Assurance and Performance Improvement (QAPI) program, as required. Specifically, a cook hired on 10/2/23 received QAPI training only at the time of hire and did not receive any subsequent annual QAPI training. During the survey, the surveyor requested in-service training records for selected staff, including the cook, and found no evidence of annual QAPI training after the initial session. When questioned, the administrator confirmed that there was no record of the required annual training for the cook and acknowledged responsibility for ensuring non-nursing staff receive their required training.
Inaccurate and Unclear Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings were accurate and clearly presented, as required by facility policy. Review of staffing schedules and posted census information revealed multiple discrepancies, including mismatches in the number of Certified Nursing Assistants (CNAs) and their hours worked, as well as inconsistencies in the inclusion of trainees and medication technicians in the posted numbers. On several occasions, the census postings were not presented in a clear or readable format, and the actual staff present did not match the posted information. These inaccuracies were observed across various shifts and dates, affecting the documentation of both licensed and unlicensed nursing staff responsible for resident care. Interviews with the scheduler and the Nursing Home Administrator confirmed that the postings should accurately reflect staff present and their hours, and that trainees should not be counted in CNA hours. However, the scheduler acknowledged that some nurses included trainees in the count, and that postings were not always updated to reflect staff leaving early or calling off. The responsibility for updating the postings was shared between the scheduler and nursing staff, but the process was not consistently followed, resulting in inaccurate and unclear staffing information being made available to residents and visitors.
Failure to Provide Person-Centered Care and Timely Notification of Changes
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices for two residents. One resident with a history of depression and recent surgery was admitted without a care plan containing resident-specific interventions for depression. This resident exhibited multiple depressive behaviors, including social isolation, refusals of care, and consistently low meal intake. Despite documentation of a significant 15.7% weight loss within 15 days of admission, the primary Nurse Practitioner was not notified, and no timely interventions were implemented. The dietician recommended a trial of Prostat for nutritional supplementation and a possible psychological evaluation, but no physician order was placed, and there was no evidence of interdisciplinary team consultation regarding the resident's nutrition. The resident continued to refuse meals and fluids, resulting in critically low fluid intake and minimal urine output over several days, yet neither the dietician nor the primary care provider was notified. When the resident's condition deteriorated, STAT labs were ordered but not processed as such, leading to delayed results. The resident was ultimately hospitalized with severe sepsis, C-diff infection, pulmonary embolism, and hypokalemia, and required intensive care. Upon return, the resident continued to have low intake and was readmitted to the hospital for dehydration and low potassium. Another resident experienced a fall from bed and was diagnosed with a closed head injury. Facility policy required neurological checks after a fall with head injury, but there was no evidence that these checks were completed. This failure to follow established protocols for post-fall assessment represents a deviation from professional standards of care. The facility's own policies outlined the need for person-centered behavioral health services, timely notification of changes in resident condition, and appropriate care planning and implementation. However, there were discrepancies among staff regarding responsibility for care plan development, and documentation showed a lack of communication and follow-through on critical changes in residents' conditions. The failures included not recognizing and addressing depressive symptoms, not responding to significant weight loss and poor intake, not notifying providers of critical changes, and not completing required post-fall assessments.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and treatment to prevent and heal pressure injuries for two residents who were at risk or had existing pressure injuries. For one resident with multiple comorbidities including diabetes, ESRD, and mobility impairment, there was a lack of documentation and implementation of physician-ordered interventions such as floating heels and use of heel boots. Despite orders in place, the Treatment Administration Record (TAR) did not reflect that these interventions were carried out, and the care plan was not updated in a timely manner to include necessary devices like bed extenders. The resident developed a deep tissue injury (DTI) to the right heel, and there were inconsistencies and omissions in wound documentation and descriptions. Interviews with staff indicated confusion regarding the cause of the wound and the application of appropriate interventions, with some staff attributing the injury to the resident's foot being against the footboard and others to underlying medical conditions. Observations confirmed that interventions were not consistently in place, and the resident reported inconsistent use of protective devices. Another resident, admitted without pressure injuries but assessed as at moderate and later very high risk for developing them, did not have new care plan interventions initiated after risk increased. Although there was a physician order to float heels, there was no documentation that this was done prior to the development of a Stage 1 pressure injury, which progressed to a DTI. Staff interviews confirmed that heel boots were not in use before the injury was identified, and documentation supported that interventions were only implemented after the pressure injury was found. The resident also experienced significant weight loss and poor oral intake, with delayed initiation of nutritional supplementation despite dietary recommendations. The care plan and TAR did not reflect timely or adequate implementation of preventive measures or documentation of compliance with interventions. The facility's own policy requires individualized, evidence-based interventions for residents at risk for pressure injuries, including implementation and documentation of physician orders, regular skin assessments, and timely updates to care plans. In both cases, the facility did not follow its policy regarding prevention, documentation, and timely intervention for pressure injuries. The lack of consistent documentation, delayed implementation of preventive devices, and failure to update care plans contributed to the development and progression of pressure injuries in these residents.
Failure to Prevent and Investigate Resident Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for multiple residents. Several residents with significant cognitive and physical impairments experienced falls that were not thoroughly investigated, and care plans were not consistently followed or updated to reflect their needs. In multiple instances, required interventions such as low bed positioning, fall mats, and accessible call lights were not in place at the time of the falls, despite being documented in the residents' care plans. One resident with severe cognitive impairment and a history of falls was found on the floor in a wet environment, having removed their incontinence brief, with the bed in the lowest position but the floor mat only partially in place. The investigation did not include staff statements to determine when the resident was last checked or if all interventions were in place, and the root cause of the fall was not determined. Another fall for the same resident occurred while the resident was reaching for a call light that was not accessible, and again, the investigation lacked staff statements and a clear root cause analysis. A second resident, who was dependent on staff for transfers and had a history of bilateral leg amputation, fell from bed during care by two aides. The bed was found in a high position and the fall mat was not in place, contrary to the care plan. The investigation did not include complete witness statements, did not address the bed height, and did not document neurological checks after the resident sustained a closed head injury. A third resident, with multiple comorbidities and mobility impairments, fell from a wheelchair after returning from dialysis. The fall investigation was incomplete, lacking documentation of mental status, predisposing factors, staff statements, and a thorough root cause analysis. The care plan was not updated to reflect the need for increased monitoring or specific interventions after the fall, and there was no documentation of when the resident was last seen prior to the incident.
Insufficient Staffing Levels Compromise Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple instances of inadequate staffing levels across various shifts. On one occasion, two CNAs called in for the evening shift, leaving only one LPN responsible for 30 residents. Recent staffing changes further reduced the number of CNAs and dietary aides scheduled per shift, resulting in only one CNA on duty during certain night shift hours, despite the facility's census and the high acuity of resident care needs. The facility's own assessment indicated a need for more staff than were actually scheduled, and the Director of Nursing and Assistant Director of Nursing were frequently required to work as floor nurses to cover gaps. Residents in the facility had significant care requirements, including 12 needing a Hoyer lift, 6 requiring two-person assistance for transfers, and several needing specialized dietary support or feeding assistance. The reduction in staffing led to delays in meal service, incomplete documentation by CNAs, and staff expressing concerns about their ability to provide adequate care. Staff interviews revealed that the changes were made due to perceived overstaffing and a stable census, but the result was increased dissatisfaction among staff, with some refusing to pick up extra shifts or complete required documentation as a form of protest. Multiple staff members, including the scheduler, dietary director, and CNAs, reported their concerns to management, noting that the new staffing levels were insufficient and created unsafe conditions for both residents and staff. The facility did not utilize agency staff to fill gaps, and the lack of adequate coverage was acknowledged by facility leadership. The surveyor also noted that the facility did not always have a second staff member with BLS certification available, despite many residents having full code status.
Deficient Infection Prevention and Control Program and Lapses in Medication Administration
Penalty
Summary
The facility failed to implement an effective Infection Prevention and Control Program (IPCP), as evidenced by multiple deficiencies in documentation, surveillance, and infection control practices. The facility's water management plan (WMP) was outdated, listing previous staff as responsible team members and lacking current verification of control measures. The Infection Preventionist (IP) was not included in the WMP team, and the current Director of Nursing (DON), who was serving as the IP, had not completed infection control training. The Director of Maintenance reported conducting weekly water testing and maintenance activities but did not retain documentation of these actions, including chlorine testing and water temperatures. Infection surveillance reports for several months were incomplete, lacking definitions for infections, identification of infectious organisms, and documentation of corrective actions taken in response to identified infections. The reports listed various infections, such as skin conditions, urinary tract infections, pneumonia, and eye infections, but did not provide sufficient detail or evidence of follow-up. Interviews with facility leadership revealed a lack of awareness regarding the deficiencies in the surveillance program and the absence of supporting documentation for infection control activities. Additionally, infection control practices during medication administration were not followed. The DON was observed administering eye drops to a resident without donning gloves, contrary to the facility's protocol, which requires hand hygiene, glove use, and subsequent hand hygiene. The DON confirmed knowledge of the correct procedure during an interview but failed to implement it during the observed medication pass. These deficiencies had the potential to affect all residents in the facility.
Lack of Designated and Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) responsible for the Infection Prevention and Control Program (IPCP), as required by its own policy and regulatory standards. Record review and staff interviews revealed that the Director of Nurses (DON) was identified as the current IP, but had not completed the necessary infection prevention and control training. The Assistant Director of Nursing (ADON) was also still in training for the IP position, and neither had obtained specialized infection control training prior to assuming the role. The facility's policy requires the IP to be qualified by education, training, experience, or certification, and to have completed specialized IPC training, which was not met in this case. Additionally, the facility assessment did not include the IP role or specify the required hours for the position, despite policy requirements that the IP's time and involvement be determined by the facility assessment. The assessment only documented that the IPCP was maintained by the DON or designee, without identifying a specific IP role. Interviews with the Nursing Home Administrator (NHA), DON, and ADON confirmed the lack of a designated, qualified IP and the absence of required training, affecting all 30 residents in the facility.
Uncovered Designated Smoking Area Fails to Meet Facility Policy
Penalty
Summary
The facility failed to provide a safe and protected designated smoking area for residents who smoke, as required by its own policy. The designated smoking area was not covered or protected from weather events and was located adjacent to the facility parking lot and circle driveway. Review of the facility's policy indicated that safety measures for the designated smoking area should include protection from weather, such as a covered area. Resident Council meeting minutes from several months documented that residents were repeatedly reminded to use the designated smoking area. During a group meeting with several residents, it was reported that smoking residents often chose to smoke under the entrance overhang instead of the designated area because the designated area was uncovered and farther away. One resident who uses a wheelchair stated they could not go out to smoke when it was raining. Other residents confirmed that smoking often occurred in front of the entrance rather than in the designated area. The Nursing Home Administrator, who started working at the facility recently, was unaware of the requirement for weather protection in the smoking area and could not provide further information about why the area was not covered.
Failure to Re-Evaluate Physical Restraint Use
Penalty
Summary
The facility failed to ensure ongoing re-evaluation of the need for a seatbelt used as a physical restraint for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including unspecified convulsions and cognitive communication deficit, was initially assessed for seatbelt use in the wheelchair on 10/11/23. Since that initial assessment, there was no evidence of a comprehensive re-evaluation of the restraint, despite facility policy requiring ongoing assessment and documentation of the need for restraints, as well as attempts at less restrictive alternatives. Observations by surveyors revealed that the seatbelt was in use during meals, contrary to a physician order to remove the self-release belt at meals. Staff interviews indicated that the seatbelt was believed to be necessary for the resident's safety due to poor balance and seizure history, and that the resident could release the belt when prompted. However, staff were unable to provide documentation of any reassessment of the restraint's appropriateness or effectiveness since the original evaluation, and the care plan had not been updated to reflect ongoing review. The resident's medical record and care plan referenced the use of the seatbelt for positioning and safety, with interventions such as releasing the seatbelt twice daily and reassessing for potential reduction. Despite these interventions, the facility could not provide evidence of ongoing comprehensive assessment or documentation as required by policy, and the restraint was not accurately reflected in the most recent MDS. This lack of ongoing evaluation and documentation led to the deficiency cited by surveyors.
Failure to Notify Law Enforcement of Alleged Physical Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and proper reporting of an alleged incident of staff-to-resident physical abuse. A resident with a history of alcohol dependence and epilepsy, who was assessed as cognitively intact and independent with activities of daily living, alleged that a Certified Nursing Assistant (CNA) hit them on the head. The facility completed a Facility Reported Incident (FRI) and submitted it to the state agency, but the documentation did not indicate that law enforcement was notified, as required by the facility's abuse policy. The section for law enforcement notification on the FRI was marked as 'no.' Interviews with facility staff confirmed that law enforcement was not contacted at the time of the allegation. The Nursing Home Administrator (NHA) stated that they did not believe a crime had occurred due to the lack of physical evidence and the resident's alertness and lack of request for police involvement. The Vice President of Clinical Services acknowledged awareness of the requirement to notify law enforcement in cases of alleged physical abuse. The resident later stated they did not recall the incident and had no concerns with staff, but the initial failure to notify law enforcement as per policy constituted the deficiency.
Failure to Document and Offer Required Immunizations
Penalty
Summary
The facility failed to ensure that eligible residents were offered and appropriately documented for influenza and pneumococcal vaccinations, as required by their own policies and procedures. Specifically, one resident with diagnoses including type 2 diabetes mellitus and acute/subacute respiratory conditions had no documentation of any pneumococcal vaccine being offered or administered, nor any record of refusal or contraindication. The Wisconsin Immunization Registry also did not show any pneumococcal vaccine for this resident, and there was no evidence in the facility records that the vaccine was offered. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the absence of documentation and indicated that the DON was still familiarizing themselves with the facility's records. Another resident, admitted with severe morbid obesity and pneumonia, had no documentation of being offered or receiving the influenza vaccine for the current timeframe, nor any record of contraindication or refusal. The facility's policies require that residents be assessed and offered these vaccines, with proper documentation in the medical record, including education provided and the outcome of the offer. The surveyor's review found that these requirements were not met for the two residents reviewed, resulting in a deficiency related to immunization practices and documentation.
Failure to Involve Activated HCPOA in Care Planning
Penalty
Summary
The facility failed to provide the opportunity for a resident with an activated Healthcare Power of Attorney (HCPOA) to participate in the development and implementation of their person-centered plan of care. The resident, who was admitted with diagnoses of Cerebral Palsy and Chronic Obstructive Pulmonary Disease, had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment and inability to make daily decisions. Despite this, the facility did not formally invite the resident's activated HCPOA to attend quarterly care conferences, as confirmed by both the HCPOA and the facility's social worker. Upon review, the facility was unable to provide documentation that care conferences were held for the resident or that invitations were extended to the resident and their activated HCPOA over the past 12 months. Interviews with facility staff confirmed that activated HCPOAs should always be invited to such conferences, but no evidence was provided to show this occurred for the resident in question.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident, as required by its own policy. The resident was admitted with a right tibia fracture status post open reduction and internal fixation surgery, as well as a diagnosis of major depressive disorder. Despite being cognitively intact and having specific medical needs, including the use of a leg brace and medication for depression, no baseline care plan was found in the electronic medical record. The absence of this care plan meant that person-centered interventions addressing the resident's depression, antipsychotic medication use, and post-surgical care were not documented or initiated as required. Interviews with facility staff, including the social worker, RN, and DON, revealed confusion and lack of clarity regarding who was responsible for initiating and entering the baseline care plan. The social worker confirmed meeting with the resident on the day of admission to review paperwork and discharge planning but did not discuss care planning. The RN and DON both expressed uncertainty about their roles in the baseline care plan process, and the DON was unable to locate the required documentation. The facility did not follow its own policy, which mandates the development and implementation of a baseline care plan within 48 hours of admission.
Failure to Monitor for Adverse Reactions to Anticoagulant Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure adequate monitoring for adverse reactions to high-risk anticoagulant medications for three residents who were prescribed Eliquis. Each resident had physician orders for Eliquis due to conditions such as chronic embolism, thrombosis, cerebral infarction, and congestive heart failure. Despite these orders and the known risks associated with anticoagulant therapy, the facility did not implement or document medication monitoring for potential adverse side effects in the residents' medical records. For each resident, the care plans included interventions to monitor for adverse reactions and signs or symptoms of bleeding, such as tarry stools, blood in urine, bruising, and petechiae. However, upon review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) for the relevant periods, surveyors were unable to locate any evidence of medication monitoring related to the use of Eliquis. This lack of documentation was consistent across all three residents reviewed. Interviews with the Director of Nursing confirmed that residents receiving anticoagulant therapy should be monitored for side effects every shift by nursing staff. When informed of the absence of medication monitoring documentation, facility leadership did not provide any additional information or evidence to demonstrate that such monitoring had occurred. The deficiency centers on the facility's failure to follow through with required monitoring practices for residents on high-risk medications, as outlined in their care plans and standard protocols.
Lack of Care Plan and Side Effect Monitoring for Psychotropic Medication
Penalty
Summary
A resident with a diagnosis of Major Depressive Disorder was admitted to the facility and was actively prescribed Fluoxetine, a psychotropic medication, for depression. The resident was noted to be cognitively intact and exhibited verbal behavioral symptoms directed toward others as well as episodes of rejecting care. Despite these clinical indicators and the ongoing use of a psychotropic medication, there was no care plan in place addressing the resident's depression or the use of psychotropic medication. Record review by the surveyor revealed that the facility did not document any monitoring for side effects associated with Fluoxetine. Interviews with nursing staff, including an RN and an LPN, confirmed that a care plan should have been in place for residents prescribed psychotropic medications and that side effect monitoring should be documented. However, neither a care plan nor side effect monitoring documentation was found in the resident's medical record. Further interviews with facility staff, including the Social Worker and Director of Nursing, revealed confusion and inconsistency regarding responsibility for initiating and maintaining care plans for residents on psychotropic medications. Both acknowledged that a care plan should exist for the resident's depression and medication use, but none could locate such documentation. The absence of a care plan and side effect monitoring for a resident receiving psychotropic medication constituted the identified deficiency.
Failure to Provide Appropriate Seizure Management and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care in accordance with professional standards for several residents, notably for a resident who experienced a change in condition due to seizures. This resident, who had no prior history of seizures, experienced multiple seizures over a period of time. The facility did not assess the etiology of the seizures, develop a seizure care plan, or monitor the resident closely for seizure activity. Additionally, there was a significant delay in processing and administering prescribed medications, including Lorazepam and Levetiracetam, which were critical for managing the resident's seizure activity. The resident continued to experience seizures and was eventually transferred to the hospital, where they expired. Other residents also experienced deficiencies in care. One resident received Midodrine despite having a systolic blood pressure greater than the threshold specified in the physician's order. Another resident had an order to check their heart rate three times a day, but the facility failed to document this consistently. Additionally, a resident with Moisture Associated Skin Damage did not receive weekly wound assessments, and the facility delayed making a necessary surgical appointment for a hernia. The facility's policy on notifying changes in a resident's condition was not adhered to, as evidenced by the lack of communication with physicians regarding changes in residents' conditions. The Wisconsin Nurse Practice Act outlines the nursing process, which includes assessment, planning, intervention, and evaluation, but these steps were not adequately followed. The facility's failure to implement these standards led to a finding of Immediate Jeopardy, indicating a reasonable likelihood of serious harm.
Removal Plan
- Education for all licensed nursing staff on change of condition and responsibilities that include collaboration with the physician, identification of necessary interventions, and the effectiveness of those interventions and implementing new interventions
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, resulting in significant deficiencies. One resident, who had a history of multiple medical conditions including diabetes, hypertension, and chronic kidney disease, experienced a change in condition with the onset of seizures. Despite receiving physician orders for medications such as Lorazepam and Levetiracetam to manage these seizures, the facility did not ensure these medications were picked up and administered in a timely manner. This failure led to the resident experiencing multiple seizures, ultimately resulting in hospitalization and subsequent death. The facility's inaction in reconciling medication orders and ensuring proper communication and collaboration with the pharmacy and hospice services contributed to the deficiency. The resident did not receive prescribed medications due to missing signatures on prescriptions and delays in medication delivery. This lack of coordination and oversight created a situation of Immediate Jeopardy, as the resident continued to suffer from seizures without the necessary medical intervention. Additionally, the facility demonstrated a pattern of delayed medication administration for other residents, with medications not being administered within the required time frame. This included instances where scheduled medications were given hours after the prescribed time, further indicating systemic issues in the facility's medication management processes. These deficiencies highlight the facility's failure to adhere to its own medication administration policies, resulting in potential harm to its residents.
Removal Plan
- Education for all licensed nursing staff on steps to take when receiving new orders, ensuring medication is monitored for effectiveness by shift to shift report, use of the 24 hour board, effective documentation.
- Licensed nursing staff education on using the SBAR when communicating with providers to ensure the information is the most up to date and factual based on current observations by the licensed nurse.
- All licensed nurses will be educated on the use of PRN medications when appropriate.
- Nurses will be educated on the process to follow when orders cannot be carried out as written by the provider.
- All licensed nurses educated on steps to take when medications do not arrive timely that include provider, pharmacy, and Director of Nurses.
- The facility has reviewed and education for all licensed nursing staff on the following policies: medication administration.
- System implemented will review 24 hour charting, review all appointments and all incoming medical records in clinical stand up meeting to ensure all new orders are reviewed from all sources: new and readmissions, telephone orders, provider visits including hospice.
- Nurse managers and DON will conduct random audits to ensure all orders from all sources are checked for accuracy, timeliness, and availability. Root cause analysis will be conducted.
- All audits will be reviewed at QAPI for further recommendations. Medical Director will be included in QAPI and reviewing the root cause analysis.
Failure to Conduct CNA Performance Reviews
Penalty
Summary
The facility failed to complete performance reviews for four out of five Certified Nursing Assistants (CNAs) reviewed, which had the potential to affect all 35 residents residing in the facility. The CNAs in question were hired on various dates ranging from 2001 to 2023, yet no performance evaluations were found for the specified timeframes. The Director of Nursing (DON) confirmed that performance evaluations should be completed yearly but could not provide any for the CNAs in question. The Nursing Home Administrator and the DON were informed of these findings, but no additional information was provided to explain why the evaluations were not conducted as required.
Governing Body Fails to Maintain HVAC System, Affecting Resident Comfort
Penalty
Summary
The facility's governing body failed to ensure the proper maintenance and operation of the HVAC system, which resulted in inadequate heating in the north hallway of the facility. The issue began when one of the furnaces on the roof malfunctioned, leading to cooler temperatures in the affected area. The Maintenance Director (MD-I) attempted to address the problem by ordering and installing parts, but the heating system remained only partially functional. Despite efforts to move residents to warmer areas, some residents refused to relocate, and temperatures in their rooms fell below the comfortable range of 71 to 81 degrees Fahrenheit. The Nursing Home Administrator (NHA-A) was initially unaware of the ongoing heating issues, which had persisted for over a month. Upon being informed, NHA-A provided a Performance Improvement Plan (PIP) that outlined the steps taken to address the problem, including ordering parts and engaging a commercial HVAC company for repairs. However, the heating system continued to experience issues, and the facility struggled to secure timely service from HVAC contractors. Temperature logs revealed that the north hallway consistently recorded temperatures below the acceptable range for extended periods. The Director of Nursing (DON-B) became aware of the heating issue upon starting at the facility in late December. DON-B expected daily temperature checks and noted that residents would need to be moved if temperatures dropped below 60 degrees Fahrenheit. Despite these measures, the facility's governing body failed to maintain a contract with an HVAC contractor, which contributed to the prolonged heating issues. The Regional Maintenance Director (RMD-GG) indicated that the facility's previous contract with an HVAC contractor was canceled, possibly due to financial reasons, leaving the facility without regular maintenance for the HVAC system.
Failure to Provide Required Effective Communication Training
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) received the required annual Effective Communication training. This deficiency was identified during a survey where both staff interviews and record reviews were conducted. The facility's policy mandates that CNAs receive at least 12 hours of in-service training annually, which includes Effective Communication as a minimum requirement. However, the survey revealed that CNAs identified as CNA-H, CNA-J, CNA-DD, CNA-EE, and CNA-FF did not receive this training within their respective annual periods based on their hire dates. The Director of Nursing (DON) acknowledged the absence of training records for these CNAs and indicated that the records might be stored offsite. Despite subsequent attempts to locate the documentation, the facility was unable to provide evidence that the required training had been completed. The surveyor confirmed with the DON that the facility is aware of the federal regulations requiring annual training, yet no documentation was found to support compliance for the CNAs in question.
Failure to Provide Required QAPI Training to CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) received the mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through staff interviews and record reviews, which revealed that CNAs H, J, DD, EE, and FF did not receive the required QAPI training. The facility's policy mandates at least 12 hours of in-service training annually, including QAPI training, but documentation for these CNAs was not found. The Director of Nursing (DON) acknowledged the absence of training records and indicated that they might be stored offsite, but no further documentation was provided to confirm the completion of the required training. The surveyors requested training records for the specified CNAs based on their hire dates, but the facility could not provide evidence of QAPI training for any of them. Despite receiving additional information on other training topics, the facility failed to demonstrate compliance with the federal regulations requiring annual QAPI training. This oversight had the potential to affect all 35 residents in the facility, as the CNAs were not adequately trained on the elements and goals of the facility's QAPI program.
Failure to Provide Annual Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that staff received the required annual Compliance and Ethics training, which had the potential to affect all 35 residents in the facility. The deficiency was identified through staff interviews and record reviews, revealing that five Certified Nurse Aides (CNAs) did not receive the necessary training. The facility's policy mandates at least 12 hours of in-service training annually, including compliance and ethics programs, but documentation for these trainings was not found for the CNAs in question. The Director of Nursing (DON) acknowledged the absence of training records and indicated that they might be stored offsite. Despite requests for additional information, the surveyors confirmed that the CNAs did not receive the required training. The facility's Facility Assessment Tool policy did not include Compliance and Ethics training, contributing to the oversight. The surveyors reviewed the regulations with the DON, but no further documentation was provided to demonstrate compliance with the training requirements.
Deficiency in Behavioral Health Training for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nurse Aides (CNAs) received the necessary behavioral health training to care for residents diagnosed with mental, psychosocial, a history of trauma, or substance use disorders, as indicated in the facility assessment. The facility's policy mandates that CNAs receive at least 12 hours of in-service training annually, which should include training on behavioral health. However, upon review, it was found that CNAs H, J, DD, EE, and FF did not receive this required training within their respective employment periods. The Director of Nursing (DON) was unable to provide documentation of the required training for the CNAs when requested by surveyors. Although additional information was later submitted, it confirmed that none of the CNAs had received the necessary behavioral health training. This lack of training is contrary to the facility's policy and federal regulations, which require annual training based on the needs of the residents and the facility assessment.
Heating Unit Malfunction Leads to Uncomfortable Environment
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for residents on the north side of the building due to a malfunctioning heating unit. The heating unit, which supplied heat to this area, was not fully operational, resulting in temperatures consistently below the required range of 71 to 81 degrees Fahrenheit. This issue persisted from November 21, 2024, with temperatures recorded as low as 57 degrees Fahrenheit in some resident rooms. Despite efforts to repair the unit, including ordering parts and engaging commercial HVAC contractors, the problem remained unresolved for an extended period. Residents residing in the affected area were offered the option to move to other parts of the facility where the heating was functional. However, several residents chose to remain in their rooms despite the cold temperatures. The facility provided extra blankets and encouraged residents to keep their doors open to mitigate the cold, but these measures were insufficient to maintain a comfortable environment. Interviews with residents revealed that some were using multiple blankets and wearing additional clothing to stay warm, indicating discomfort due to the inadequate heating. The facility's maintenance director and other staff were aware of the heating issues and took temperature readings multiple times a day. However, the facility's response was delayed and ineffective, as the heating unit continued to malfunction intermittently. The nursing home administrator and director of nursing were informed of the situation, and a performance improvement plan was initiated, but the heating issues persisted, affecting the residents' right to a safe and comfortable living environment.
Failure to Notify Physicians and Representatives of Changes
Penalty
Summary
The facility failed to ensure that the physicians and/or resident representatives were notified of changes in the condition or treatment of two residents, leading to a deficiency. For one resident, the facility did not notify the guardian of a KUB x-ray, stool culture, and labs ordered by the physician. Additionally, the resident's physician was not informed when medications scheduled to be administered BID/TID were given late over a period of several weeks. Interviews with facility staff confirmed that the guardian and physician should have been notified, but there was no documentation to support that this occurred. Another resident experienced similar issues with late medication administration without the physician being notified. This resident had a history of diabetes mellitus, congestive heart failure, and other chronic conditions. Medications, including insulin and other critical drugs, were administered late on multiple occasions. Staff interviews revealed that the protocol required notifying the physician and documenting the notification, but this was not done. The facility's policy on Notification of Changes, which mandates immediate communication with the resident, their representative, and the attending physician regarding changes in condition or treatment, was not followed. The lack of documentation and communication regarding the late administration of medications and new orders contributed to the deficiency identified by the surveyors.
Inadequate Investigation of Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate a resident-to-resident altercation involving two residents, R14 and R15, who were reviewed for an allegation of abuse. The incident occurred when R15, who was in a wheelchair, became upset with R14 for not moving fast enough and kicked R14 in the left shin. The Facility Reported Incident (FRI) did not include statements from other residents to assess their feelings of safety or any previous interactions with R15. Additionally, the FRI lacked comprehensive staff statements that could provide insight into the behaviors or mood of R14 and R15 prior to the altercation. The facility's policy on abuse, neglect, and exploitation requires a thorough investigation, including identifying and interviewing all involved parties and documenting the investigation comprehensively. However, the FRI only contained a statement from one Certified Nursing Assistant (CNA-H) who witnessed the incident, and no other staff statements were collected to address the residents' behaviors earlier in the day. The Interim Nursing Home Administrator (iNHA)-N noted that no other staff witnessed the incident, and the FRI did not include any documentation of education provided to staff to prevent future altercations. Interviews with staff, including CNA-H and LPN-E, confirmed the lack of additional statements and education following the incident. CNA-H and LPN-E both stated that R15 had not displayed concerning behaviors prior to the incident, and there were no previous altercations between R14 and R15. The Nursing Home Administrator (NHA)-A, who was not the acting administrator at the time, acknowledged the absence of resident statements and education in the FRI but did not provide further information to address these deficiencies.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for a resident, identified as R6, who was reviewed for falls. During a bed bath, R6 was rolled in bed from one side to another when the bed moved away from the wall, resulting in R6 falling to the floor. R6 immediately complained of pain and was sent to the emergency room for further evaluation. The care plan for R6 required that all care be provided with two staff members present, and R6 should have been rolled towards the staff member, not away from them, to prevent a fall from the bed. R6 was admitted to the facility with diagnoses including major depressive disorder, anxiety disorder, schizoaffective disorder, and morbid obesity. The resident was assessed to need partial/moderate assistance for bed mobility but was dependent on staff for rolling left and right during bed mobility. The care plan indicated that R6 sometimes exhibited behaviors such as cursing and hitting during care, and interventions included providing care in pairs for all needs. However, on the day of the incident, only one CNA was present, and the care plan was not followed. The CNA involved in the incident stated that she was not aware that R6 required care in pairs and that R6 assisted by grabbing the headboard and pushing against the wall, which caused the bed to move. The Director of Nursing, who was not in the position at the time of the incident, acknowledged that the care plan was not followed and that the resident should have been rolled towards the staff member for safety. The facility's falls investigation noted the bed position as a predisposing environmental factor but did not address the lack of adherence to the care plan requiring two staff members.
LPN Competency Assessment Not Completed
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) completed the required competency assessment after being hired. The LPN, identified as LPN-K, was hired on September 15, 2024, but did not have a completed Licensed Nurse Competency assessment. This deficiency was identified during a survey conducted on January 6 and 7, 2025. An anonymous complainant informed the surveyor that new employees were not receiving the necessary training and orientation, which should include following a nurse for four weeks to become oriented and competent. However, this process was reportedly not being implemented. The Business Office Manager/Human Resource (BOM/HR) was responsible for onboarding and stated that competencies for new hires should be completed before they work independently. Despite this, the BOM/HR could not locate the competency for LPN-K and acknowledged the need for a better orientation process. The BOM/HR was able to provide competencies for two Certified Nursing Assistants (CNAs) hired around the same time but not for LPN-K. The Nursing Home Administrator and Director of Nursing were informed of the missing competency for LPN-K, but no explanation was provided for the oversight.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 5.88 percent due to two medication errors. The first error involved a resident's Lispro insulin bottle, which was not dated when opened. This was observed by a surveyor when an LPN administered insulin to the resident without verifying the expiration date, as the vial lacked a date. The LPN acknowledged the oversight and disposed of the insulin vial and syringe, indicating a failure to adhere to the facility's medication administration procedures. The second error occurred when another resident received Metoprolol Succinate ER 25 mg without having their blood pressure and heart rate checked beforehand, as required by the physician's orders. The LPN administering the medication admitted to the surveyor that vital signs should have been taken prior to administration. This oversight was confirmed upon review of the resident's physician orders, which specified holding the medication if the systolic blood pressure was under 110 or the heart rate was below 60. These actions contributed to the facility's medication error rate exceeding the acceptable threshold.
Failure to Document Resident Treatments
Penalty
Summary
The facility failed to maintain the medical records of a resident, identified as R5, in accordance with accepted professional standards and practices. The Treatment Administration Records (TAR) for July, August, and September 2024 contained multiple blank entries for various treatments and checks, including diabetic foot checks, wound care, and the application of Nystatin powder. These blanks were not explained in the medical records, leaving it unclear whether the treatments were not completed, the resident refused them, or the licensed nurse failed to document them. R5 had a medical history that included diabetes and required regular diabetic foot checks and wound care for multiple areas, including the left great toe, left plantar foot, left proximal third toe, right anterior arm, right plantar foot, and a right foot partial amputation. The TARs showed numerous dates where these treatments were not documented as completed, spanning across three months. Despite the facility's policy requiring documentation of medication administration and refusals, the records lacked any notes explaining the absence of documentation for these treatments. The Director of Nursing (DON) acknowledged the blanks in R5's TARs but did not provide additional information to clarify the situation. The surveyor's review of R5's progress notes also failed to reveal any documentation regarding the blank dates. This lack of documentation indicates a failure to adhere to professional standards in maintaining accurate and complete medical records for the resident.
Deficiency in CNA Training on Resident Rights
Penalty
Summary
The facility failed to ensure that two of its Certified Nurse Aides (CNAs), specifically CNA-H and CNA-DD, received the required annual training on Resident Rights and the responsibilities of the facility to properly care for residents. This deficiency was identified through staff interviews and record reviews, which revealed that the necessary training documentation was not available for these CNAs within the required timeframe based on their hire dates. The facility's policy mandates at least 12 hours of in-service training annually, including training on Resident Rights, but the records showed that CNA-H and CNA-DD did not receive this training within the specified period. The Director of Nursing (DON) acknowledged the absence of training records for the specified CNAs and indicated that the records might be stored offsite. Despite subsequent efforts to provide documentation, it was confirmed that CNA-H last received Resident Rights training outside the required timeframe, and CNA-DD also did not receive the training within the year following their hire date. This oversight had the potential to impact all 35 residents in the facility, as the CNAs were not adequately trained on critical aspects of resident care and rights.
Deficiency in Required Abuse and Dementia Training for CNA
Penalty
Summary
The facility failed to ensure that one of its Certified Nurse Aides (CNA-H) received the required annual training on abuse, neglect, and dementia care. This training is mandated by both state and federal regulations and is crucial for the prevention of abuse, neglect, and exploitation of residents. The facility's policy requires at least 12 hours of in-service training annually, which includes dementia management and abuse prevention. However, documentation revealed that CNA-H did not receive the necessary dementia training within the specified timeframe from their hire date. During the survey, the Director of Nursing (DON-B) was unable to provide evidence of the required training for CNA-H and other CNAs within the specified periods. Although additional documentation was later submitted, it confirmed that CNA-H had only received abuse training, not dementia training, within the required timeframe. This oversight in training compliance had the potential to affect all 35 residents in the facility, as it compromised the staff's ability to effectively manage and prevent abuse and neglect.
Deficiency in Annual Infection Control Training for CNAs
Penalty
Summary
The facility failed to ensure that two of its Certified Nurse Aides (CNAs), specifically CNA-H and CNA-DD, received the required annual Infection Control training. This training is mandated to include written standards, policies, and procedures for infection prevention and control. The facility's policy stipulates that CNAs must receive at least 12 hours of in-service training annually, which includes infection control as a critical component. However, upon review, it was found that CNA-H, hired on 1/28/21, did not receive any Infection Control training within the specified timeframe. Similarly, CNA-DD, hired on 3/1/23, did not receive the training within the year following their hire date, with the last recorded training occurring on 4/3/24, outside the required timeframe. The deficiency was identified during a survey when the Director of Nursing (DON) was unable to provide documentation of the required training for the CNAs in question. Despite the facility's policy and the federal regulations mandating such training, the records were either not maintained or not accessible at the time of the survey. The DON acknowledged the oversight and indicated that the training records might be stored offsite, but no additional information was provided to confirm the completion of the required training within the stipulated period. This lapse in training documentation and compliance with infection control training requirements had the potential to affect all 35 residents in the facility.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant issue with flies throughout the building. Observations by surveyors noted the presence of flies in various areas, including resident rooms, hallways, the common dining room, and a conference room. Residents reported the persistent problem, with some taking personal measures such as purchasing sticky fly strips or using fly swatters to manage the nuisance. The facility's pest control policy, dated April 2024, mandates regular and scheduled pest control services, but the facility did not have a pest control company servicing the building in June and July 2024. Interviews with staff and residents confirmed the ongoing issue with flies. Residents expressed frustration, and staff acknowledged the problem, noting that flies were particularly prevalent in certain areas of the facility. The Director of Maintenance admitted that the facility switched pest control companies after May and did not have invoices for June and July, indicating a lapse in pest control services during those months. Despite the presence of a new pest control company starting in August, the issue with flies persisted, as evidenced by surveyor observations and resident complaints. The deficiency affected all 58 residents in the facility, as flies were observed in multiple locations, including resident rooms and common areas. The facility's failure to address the fly problem effectively, as outlined in their pest control policy, contributed to the ongoing issue. The lack of documentation for pest control services during June and July further highlights the facility's inadequate pest management efforts during this period.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by the conditions observed in one resident's room and the facility's grounds. A resident's shared bathroom was found to have a dried and crusted brown material, suspected to be bowel movement, on the wall near the call light, and the floor was sticky. The resident's room also had paint scrapings and plaster gouges behind the headboard. The resident, who is severely cognitively impaired and incontinent, does not use the bathroom due to its unclean state, as confirmed by their Power of Attorney. The facility's housekeeping and maintenance practices were inadequate, as shared bathrooms were not cleaned daily, even when one of the adjoining rooms was unoccupied. The Housekeeping Director stated that shared bathrooms should be cleaned every day, but the bathroom in question was not cleaned by the time it was observed by the surveyor. Additionally, the Director of Maintenance was unaware of when resident rooms were last painted and only addressed paint concerns upon a resident's discharge. The facility grounds were also found to be littered with various items, including a towel, hairnet, cigarette butts, a face mask, blue gloves, and a broken wheelchair. The Director of Maintenance and Housekeeping Director had conflicting views on who was responsible for cleaning the outside areas. The Nursing Home Administrator was informed of these environmental concerns, but no further information was provided to address why the facility did not ensure a clean and homelike environment.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the care needs of residents, particularly affecting those on the north unit. On a specific day, a Certified Nursing Assistant (CNA) was reassigned to pass medications, leaving her original assignment unattended. This resulted in a resident's call light being on for over two hours, during which the resident was visibly upset and crying due to unmet toileting needs. The CNA did not inform other staff of the resident's needs, and the call light remained unanswered for an extended period, highlighting a significant staffing issue. Multiple residents reported long wait times for call lights to be answered, indicating a systemic problem with staffing levels. One resident, who is cognitively intact and dependent on assistance for toileting, reported frequent delays in call light responses, sometimes waiting up to three hours. Another resident's Power of Attorney noted a 45-minute wait for a call light to be answered, attributing the delay to insufficient staff. These observations were corroborated by surveyors who noted several call lights going unanswered for extended periods. The deficiency was further evidenced by interviews with residents and their representatives, who consistently reported inadequate staffing levels affecting the timeliness of care. Residents expressed frustration over long wait times for assistance, with some reporting that they had to wait over an hour for help with basic needs. The facility's failure to provide adequate staffing resulted in unmet care needs and distress among residents, as observed and documented by surveyors.
Unqualified CNA Administering Medications
Penalty
Summary
The facility was found to have insufficient nursing staff with the appropriate competencies and skill sets to ensure resident safety. A Certified Nursing Assistant (CNA) was observed administering medications to residents, a task that should be performed by licensed nurses or legally authorized staff according to the facility's Medication Administration policy. The CNA, identified as CNA-F, was observed preparing and administering medications to residents on the North unit, despite not having passed medications for two years and lacking recent training or certification. During interviews, CNA-F revealed that she was pulled from her aide position to pass medications by a Registered Nurse (RN), despite not having completed any training or in-services for over a year. CNA-F also reported issues accessing the necessary training modules, which were not resolved by the facility. The surveyor confirmed that CNA-F's employee file contained no evidence of the required training or certification to administer medications, highlighting a significant deficiency in the facility's staffing and training practices.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in multiple residents not receiving their medications as prescribed. On the North unit, residents were administered their morning medications more than two hours after the scheduled time, with one resident not receiving their pain medication as ordered. A Certified Nursing Assistant, who had not passed medications in two years, was pulled to administer medications, leading to delays and confusion. This resulted in residents receiving their medications late, and in one case, a resident refused all morning medications except for a pain pill due to the delay. Additionally, a resident did not receive their prescribed oxycodone in a timely manner. The resident requested the medication for severe pain, but it was administered over an hour and a half later than requested. The medication technician misunderstood the physician's order, administering the medication every eight hours instead of as needed, which contributed to the delay in pain management. On another occasion, a nurse was called back to the facility to cover a shift but did not administer any medications upon arrival due to uncertainty about what had been given by the previous nurse. This led to several residents not receiving their evening medications, as the nurse was uncomfortable administering medications without proper documentation. The lack of adherence to medication administration protocols and documentation standards resulted in confusion and missed doses for multiple residents.
Failure to Inform Residents of Medication Changes
Penalty
Summary
The facility failed to ensure that residents were fully informed and participated in their treatment decisions, specifically regarding medication changes. Two residents, R7 and R1, were affected by this deficiency. R7, who has a court-appointed guardian, was not informed about the administration of a newly ordered psychotropic medication, Seroquel. Despite the facility's policy requiring residents or their representatives to be educated on the risks and benefits of psychotropic drugs, there was no evidence that R7 was involved in the decision-making process or informed about the medication. The facility's records showed that the medication was administered without R7's consent, and the guardian was not documented to have discussed the medication with R7. R1, who is cognitively intact and manages their own care, was not informed of changes to their prescribed Oxycodone dosage and frequency. The facility's records indicated that R1's medication order was changed, but R1 was unaware of these changes and continued to believe the medication was to be administered every 8 hours. R1 expressed that they were not informed of any medication changes or updates to their care plan, and the last documented care conference for R1 was nearly two years prior, indicating a lack of communication and involvement in care decisions. The surveyor's interviews and record reviews highlighted the facility's failure to communicate medication changes to the residents, which is a violation of the residents' rights to be informed and participate in their treatment. The Regional Director of Clinical Operations acknowledged the issue but did not provide further information or evidence of corrective actions being taken at the time of the survey.
Resident Excluded from Care Planning Process
Penalty
Summary
The facility failed to provide a resident the opportunity to participate in the development and implementation of their person-centered plan of care. The resident, who was admitted with multiple diagnoses including PTSD, Major Depressive Disorder, and Chronic Pain Syndrome, had not been included in care planning since their last documented care conference over two years ago. Despite being cognitively intact and capable of making daily decisions, the resident reported not having a care conference to discuss their plan of care or any concerns. The facility's policy requires informing residents of their rights regarding care planning and encourages their participation in choosing care and treatment options. However, the facility did not adhere to this policy, as there was no documentation of quarterly care conferences for the resident since admission. The social worker and other facility staff were unable to provide evidence of such conferences, confirming the deficiency in involving the resident in their care planning process.
Resident's Air Conditioner Removed Without Notice
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as R1, by removing an air conditioning unit from R1's room without prior notice or explanation. R1, who has multiple diagnoses including PTSD, major depressive disorder, and chronic pain syndrome, was cognitively intact and capable of making daily decisions. The air conditioning unit was removed while R1 was at the emergency room, and upon return, R1 found the unit missing. R1 subsequently purchased a personal air conditioner to maintain a comfortable room temperature. The facility's maintenance director confirmed the installation of R1's personal air conditioner, stating that parts for the facility's unit were on order, but R1 chose not to wait. The nursing home administrator explained that the unit was removed to address warmth in the therapy room, and the regional director of clinical operations noted it was R1's choice to buy a personal unit. Observations revealed other air conditioners in common areas and another resident's room, with some units not in use. The facility did not provide further information when the concern was raised by the surveyor.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide prior written notice to two residents, R1 and R6, regarding room changes within the facility, which is a violation of the residents' rights. R1 was moved to a new room without being given a choice of available rooms or an explanation for the change. The move caused R1 significant emotional distress, as documented by the surveyor and the facility's staff. R1's medical records indicate that the resident experienced increased anxiety, depression, and agitation due to the room change, and was not provided with written notification of the move. Similarly, R6 was transferred from a private room to a shared room without receiving any written notice or explanation for the change. R6 expressed dissatisfaction with the move and reported not being given any paperwork or reason for the room change. The Director of Social Services admitted to not providing written notice and failing to document the room change process, which is contrary to the facility's policy. The facility's policy requires that residents and their representatives be given advance written notice of room changes, including the reasons for the change. However, the facility did not adhere to this policy in the cases of R1 and R6. The Nursing Home Administrator and Director of Social Services acknowledged the lack of written notice and documentation, citing reasons such as census management and changes in payer status, but did not provide further justification for the failure to comply with the policy.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
