Samaritan Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in West Bend, Wisconsin.
- Location
- 531 E Washington St, West Bend, Wisconsin 53095
- CMS Provider Number
- 525165
- Inspections on file
- 23
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 16 (2 serious)
Citation history
Health deficiencies cited at Samaritan Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain safe and palatable food temperatures during meal service, resulting in two residents receiving meals that were reported as cold. Although kitchen temperatures for items such as chicken fried steak, cheesy rice, and spinach initially met standards, delays in tray delivery to rooms and leaving the cart door open during service led to significant cooling by the time the last trays were served. A test tray checked by an RN showed entrée and side dish temperatures below 135°F, and Resident Council minutes documented repeated complaints of cold food.
Three residents experienced harm due to the facility's failure to follow physician recommendations, ensure timely imaging and consults, administer ordered antibiotics, and provide wound care according to medical orders. One resident's untreated knee infection led to hospitalization and surgery, another's wound worsened due to lack of timely treatment, and a third received wound treatments not supported by physician orders.
A resident with multiple falls and high fall risk did not have their care plan updated with appropriate interventions after each incident. Despite IDT reviews and recommendations for interventions such as auto-lock brakes and fall mats, these were not consistently implemented or documented, and the resident reported not receiving some of the suggested devices. The facility's policy for immediate intervention and care plan updates was not followed.
A resident with left-sided hemiparesis and a history of Parkinsonism and CVA required two-person assistance for bed mobility but was assisted by only one RN during care, resulting in a fall from bed and an orbital fracture. Post-fall, the facility failed to complete required neurological checks and did not notify a physician of the resident's subsequent confusion, vomiting, and swallowing difficulties. The resident died days later, with the medical examiner attributing the death to a concussion related to the fall.
Two residents' missing personal items, an iPad and a watch, were reported by their POAHCs, but the facility did not notify law enforcement or the State Agency as required. Despite internal policies mandating timely reporting of suspected misappropriation, staff and administration did not consider the incidents as misappropriation due to lack of inventory documentation or uncertainty about theft, resulting in non-compliance with federal reporting requirements.
The facility did not thoroughly investigate two separate allegations of missing personal property involving two residents, one with moderate and one with severe cognitive impairment. In both cases, the facility failed to document or conduct interviews with residents or staff as required by policy, and did not complete a thorough investigation into the reported missing items.
Three residents did not receive care and treatment as ordered by their physicians, including missed daily weights, incomplete edema assessments, and improper application and removal of TED hose and Tubigrip stockings. Staff failed to consistently follow orders for monitoring fluid retention and for the use of compression devices, resulting in residents wearing Tubigrips overnight and not receiving required assessments.
A resident with multiple serious diagnoses was observed using supplemental oxygen without a physician order or care plan addressing oxygen therapy. Staff, including a CNA and RN, were unsure about the resident's oxygen use, and the DON confirmed the absence of required documentation until it was entered during the survey. The facility's oxygen policy did not address clinical management, contributing to the deficiency.
A resident with multiple medical conditions did not receive several doses of prescribed medications, including D-Mannose, nateglinide, and pregabalin, because the medications were unavailable at the facility. Despite facility policy requiring timely administration and procedures for obtaining medications from the pharmacy, these medications were not administered as ordered over several days.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A medication cart was left unlocked and unattended in a hallway, with its computer screen displaying resident information and drawers accessible, while a resident was nearby. The responsible RN acknowledged forgetting to lock the cart when leaving to refill a water jug, contrary to facility policy requiring medication carts to be locked when not in use.
Several residents reported that meals were served cold, burned, or unpalatable, with observations confirming that food items were held below required temperatures and sometimes appeared burned. Staff were unaware of proper temperature protocols, and equipment issues contributed to the failure to maintain safe and appetizing food temperatures.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple chronic conditions and a history of pain was not assessed for pain or provided pain medication during a night shift, despite physician orders and facility policy requiring regular pain assessments and as-needed pain management. The lapse was confirmed by review of medical records and staff interview.
Three residents experienced deficiencies in medication administration, including a resident self-administering insulin without proper assessment or physician order, missing and undocumented doses of pain and other medications for another resident, and a missed injection due to lack of required lab work for a third resident. Staff failed to follow facility policy regarding medication documentation and safe administration practices.
Two residents with documented preferences for fried eggs at breakfast were not provided their preferred food item, despite repeated requests and communication with dietary staff. Instead, they were given alternative egg products, with staff citing budget, vendor supply, and staffing limitations as reasons for not fulfilling the requests. Both residents expressed dissatisfaction with the alternatives, and observations confirmed that shelled eggs were present in the facility but not used to meet resident preferences.
The facility failed to store and prepare food in a sanitary manner, affecting all 69 residents. Pre-cooked foods lacked cooling logs, and cooking temperature logs were incomplete. The three-compartment sink and sanitizer buckets were not used correctly, with sanitizer levels exceeding required PPM. The Dietary Manager admitted to filling in missing temperature logs and was unaware of proper sanitization procedures.
The facility failed to meet residents' nutritional needs by not following prescribed diet orders and serving sizes. Observations revealed incorrect serving sizes for pureed diets and non-compliance with carb-controlled and low concentrated sweets diets. Residents expressed concerns about insufficient food, and dietary staff did not adhere to diet spreadsheets, leading to improper meal service.
A facility failed to obtain court-ordered protective placement for a resident with a legal guardian, as required by state statute. The resident, admitted from a group home, had a legal guardian since 2006. Despite the requirement for protective placement documentation for residents with guardians whose stay exceeds ninety days, the facility did not have such documentation. The Social Worker acknowledged the oversight and noted the facility lacked a policy on protective placement.
The facility failed to provide three residents with timely Medicare coverage and liability notices, specifically the ABN and NOMNC forms, when their Medicare services ended. There was no documentation to confirm delivery, and interviews revealed that residents and their representatives were not informed. The facility lacked a policy and tracking system for issuing these notices.
A resident with intact cognition reported frequent interruptions during showers by staff, despite a grievance and a privacy sign being created. The communal shower room setup, with linens stored inside, led to staff entering for supplies. Some staff respected privacy by knocking, but others entered accidentally. The DON admitted not all staff were educated about the privacy sign.
The facility failed to provide safe and comfortable water temperatures for two residents, leading to complaints about cold showers and baths. Staff interviews revealed that the hot water supply was insufficient, especially when used consecutively, and the issue persisted despite some staff education. The Nursing Home Administrator was unaware of the ongoing problem, believing it had been resolved.
A resident's family member filed a grievance due to delayed lab culture results. Despite repeated inquiries, the facility failed to provide timely information or a clear resolution. The resident had intact cognition and was responsible for their healthcare decisions. The facility's grievance policy was not followed, as the family member was not kept informed throughout the process.
A resident with multiple wounds and impaired skin integrity had a pressure-relieving air mattress incorrectly set to 360 pounds instead of their actual weight of 180 pounds. The care plan lacked individualized settings for the mattress, contrary to the facility's policy. Interviews confirmed the incorrect setting, indicating a failure to provide necessary individualized care.
Two residents in the facility did not receive appropriate care to prevent urinary tract infections. One resident with severe cognitive impairment and a recent UTI was repeatedly observed with an uncovered catheter bag on the floor under their wheelchair. Another resident, on enhanced barrier precautions, had their catheter bag in contact with the floor under their bed. The facility's policy requires catheter bags to be covered and off the floor, which was not followed.
The facility failed to ensure accurate medication administration for three residents. A resident did not receive eight doses of medication due to unavailability, despite staff efforts to contact providers. Another resident missed a dose of Depakote ER because the alternative form was unavailable. An LPN administered an expired medication to a third resident and disposed of it improperly. These deficiencies highlight issues in medication availability and adherence to disposal protocols.
A resident experienced a delay in starting antibiotic treatment due to the facility's failure to ensure timely laboratory services. The resident's wound culture, collected on one date, was not sent to the lab promptly, resulting in the need for a second culture. This delay postponed the diagnosis and treatment of an infection, as confirmed by facility staff interviews.
A resident admitted to the facility did not receive their prescribed Vyvanse medication from 11/9/24 through 11/11/24 due to communication and procedural failures. The prescriber attempted to send a script to the pharmacy, but it did not go through, and the facility was not informed. The resident's family brought the medication from home, but it was not in the original container, so staff could not administer it. The resident experienced increased anxiety and was discharged against medical advice.
A resident with dementia and a stage 3 pressure ulcer did not receive the prescribed double entree for wound healing during a lunch meal. The dietary aide served a single entree despite the meal ticket indicating a double portion was required. The Food Safety Manager confirmed the oversight and acknowledged the need for training.
A resident with a history of sexually inappropriate behavior was not adequately supervised, leading to an incident where the resident engaged in inappropriate behavior with another resident who was unable to consent due to severe cognitive impairment. Despite previous incidents and documentation of inappropriate behavior, the resident was not placed under increased supervision until after the incident occurred, resulting in a finding of immediate jeopardy.
Failure to Maintain Safe and Palatable Food Temperatures During Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals were served at a palatable and safe temperature, as required by its Safe Food Handling policy and the FDA Food Code. The policy directed dining services staff to use food preparation techniques that minimize the time food is held below 135°F or above 41°F. During a meal service observation, dietary staff initially measured appropriate temperatures in the kitchen for the regular diet entrée of chicken fried steak (164°F), cheesy rice (160°F), and spinach with onions (167°F) before service. However, residents eating in the dining room were served first, and trays for residents who chose to eat in their rooms were plated afterward, with the last cart not reaching the fourth floor until later in the meal period. The cart door remained open while trays were passed, and the last tray was not served until 12:45 PM. Two cognitively intact residents reported receiving food that was not hot. One resident, admitted on a recent date with an admission MDS showing a BIMS score of 15/15, stated that their bite-sized food “could be hotter.” Another resident, with an admission MDS BIMS score of 14/15, reported that their regular diet meal was cold and that it was always cold. Resident Council minutes documented complaints of cold food at meetings held on two separate dates. A test tray taken from the last cart on the fourth floor and checked with a digital thermometer by an RN showed the chicken fried steak with gravy at 126°F, cheesy rice at 130°F, and spinach with onions at 130°F, all below the 135°F standard for food service and palatability. These observations and interviews demonstrate that the facility did not consistently maintain food temperatures during tray line and delivery to residents, resulting in meals being served below required temperatures.
Failure to Provide Timely and Appropriate Wound Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide necessary care and services to promote healing and prevent the worsening of non-pressure related wounds for three residents. One resident with a history of left total knee arthroplasty experienced ongoing pain, redness, and swelling in the left knee and lower leg. Despite repeated recommendations from wound care and medical staff for an MRI and orthopedic consult, the facility did not ensure these were completed. The MRI was canceled multiple times due to insurance concerns, and no further assistance was provided to obtain the imaging or consult. The resident received multiple courses of oral antibiotics without resolution, and a subsequent course of antibiotics was not administered as ordered. The resident was eventually hospitalized with a septic joint, underwent surgical intervention, and returned to the facility with ongoing pain and loss of function. Another resident with a history of basal cell carcinoma removal and multiple sclerosis developed a wound on the right lower extremity. An initial treatment order was entered and discontinued on the same day, and no new order was entered, resulting in a lack of assessment or treatment for nearly two weeks. During this period, the wound deteriorated and increased in size. The wound was only reassessed and treated after the resident requested to see the wound clinic, at which point antibiotics and appropriate wound care were initiated. A third resident with multiple comorbidities, including sepsis and systemic sclerosis, received wound care treatments that were not supported by physician orders. Staff applied lidocaine, gentian violet, and Iodosorb to wounds without corresponding medical orders, and substituted treatments when supplies were unavailable without documented physician approval. These actions were observed during wound care and confirmed by staff interviews, indicating a lack of adherence to established protocols for wound management and physician-directed care.
Removal Plan
- Identify other residents with current wounds and assess for signs/symptoms of infection, including redness, warmth, pain and swelling, and ensure referrals, consults, imaging, lab work, antibiotics, and wound treatments are administered.
- Educate licensed nursing staff on the facility's wound management policy and protocol to follow-up on skin issues as well as updating/documenting dressing changes.
- Review all wound orders by the DON/designee to ensure accuracy and follow-up.
- Conduct skin audits. Provide education when indicated.
Failure to Update Care Plan and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that adequate assistive devices and supervision were in place to prevent falls for a resident with a history of multiple falls. Despite the resident being identified as high risk for falls due to recent admission, prior falls, and use of psychotropic, pain, and narcotic medications, the care plan was not updated with appropriate interventions after each fall. The resident experienced falls on several occasions, including incidents where the wheelchair brakes were not locked, the resident rolled out of bed, and dizziness led to a fall resulting in a head injury. Although the interdisciplinary team (IDT) reviewed each fall and discussed possible interventions such as auto-lock brakes, fall mats, and bolsters, these interventions were not consistently implemented or documented in the resident's care plan. Interviews and record reviews revealed that the resident did not receive some of the recommended interventions, such as bolsters or a fall mat, and the care plan was not updated to reflect new or revised interventions after each fall event. The facility's policy required immediate interventions and care plan updates following falls, but these steps were not followed. The President of Clinical Operations confirmed that the care plan should have been updated after new interventions were determined, acknowledging that this did not occur for the resident in question.
Failure to Provide Adequate Supervision and Post-Fall Monitoring for Resident with Hemiparesis
Penalty
Summary
A resident with a history of Parkinsonism, cerebrovascular accident (CVA) resulting in left-sided hemiparesis, and a stage 4 sacral pressure ulcer required assistance for bed mobility. During morning care, a registered nurse (RN) was providing wound and incontinence care when the resident, who was positioned on the left side, rolled out of bed after the RN turned away to retrieve a brief. The resident struck their head on the wall and then the metal bed frame, resulting in an orbital floor blowout fracture with herniated extraconal fat. The care plan indicated the resident required assistance from two staff for bed mobility, but only one staff member was present at the time of the incident. There was confusion among staff regarding the care plan, with some believing the two-person assistance requirement was implemented only after the fall, despite documentation indicating it was in place prior to the incident. Following the fall, the facility did not ensure thorough post-fall monitoring or neurological checks as required by policy. The monitoring order was not consistent with the 72-hour minimum, and neurological checks were incomplete or missing for several shifts. The resident exhibited symptoms consistent with a concussion, including intermittent confusion, vomiting, and swallowing difficulties, as documented by hospice staff and family. Despite these changes in condition, there was no evidence that a physician was notified or that the care plan was updated to reflect the resident's deteriorating status. Interviews with staff and review of records revealed that the RN did not position the resident's flaccid side appropriately, contributing to the fall. The facility's investigation also found that staff were not fully aware of or did not follow the care plan interventions for bed mobility. Additionally, there was a lack of communication and documentation regarding the resident's post-fall symptoms and changes in condition, including episodes of vomiting and increased confusion. The medical examiner determined the resident's death was accidental, caused by a concussion in the setting of Parkinsonism, with the orbital fracture and CVA history as significant contributing conditions.
Removal Plan
- Reviewed, screened, and updated care plans for residents with diagnoses of hemiparesis and falls related to bed mobility.
- Met with Hospice staff to ensure effective communication regarding changes in condition. Updates should be given to the DON or designee before Hospice staff leave the building.
- Educated facility and agency staff on bed mobility, post-fall assessments, and changes in condition.
- Initiated bed mobility and change in condition competencies to ensure staff follow proper techniques and protocols. Ad hoc education to be provided immediately when indicated.
Failure to Report Suspected Misappropriation of Resident Property
Penalty
Summary
The facility failed to develop and/or implement policies and procedures to ensure the timely reporting of suspected misappropriation of resident property, as required by section 1150B of the Act. In two separate cases, grievances were filed by the Power of Attorney for Healthcare (POAHC) for two residents regarding missing personal items: an iPad and a watch. In both instances, the allegations of misappropriation were not reported to law enforcement or the State Agency (SA), despite the facility's own policy requiring such reporting within specified timeframes. In the first case, a resident with moderate cognitive impairment and a history of malignant neoplasm of the bladder, secondary neoplasm of the bone, and toxic encephalopathy reported a missing iPad. The resident's POAHC indicated the iPad was present before a hospital stay but missing upon return. The facility's social worker acknowledged receiving the grievance and multiple communications with the POAHC, but the incident was not reported to law enforcement or the SA. The Nursing Home Administrator (NHA) stated that the missing iPad was not considered misappropriation because it was not on the resident's inventory list and staff did not recall seeing it. In the second case, a resident with severe cognitive impairment and a diagnosis of dementia and neurocognitive disorder with Lewy bodies was reported by the POAHC to have a missing watch after the resident's death. The facility offered reimbursement, which was declined due to the watch's sentimental value. The grievance officer confirmed the facility's investigation did not include reporting the incident to law enforcement or the SA. The NHA indicated the missing watch was not considered misappropriation because the POAHC was unsure if it was stolen. In both cases, the facility did not follow its own policy or federal requirements for reporting suspected misappropriation.
Failure to Investigate Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation of property for two residents. In the first case, a resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC) reported a missing iPad, which was also reported by the POAHC. The iPad was not listed on the resident's inventory sheet, but the family indicated it had been brought in. The facility's response was limited to discussing the issue in a daily standup meeting and instructing departments to ask staff if they had seen the iPad. However, there was no documentation that the resident, other residents, or staff were interviewed, and the facility confirmed that these interviews were not completed. In the second case, a resident with severe cognitive impairment and an activated POAHC was reported to have a missing watch after their passing. The POAHC filed a grievance, and the facility offered reimbursement, which was declined due to the watch's sentimental value. The facility's investigation consisted of housekeeping and nursing staff searching for the watch, but there was no documentation of interviews with other residents or staff. The facility confirmed that a thorough investigation, including interviews, was not completed for this allegation either.
Failure to Follow Physician Orders for Compression Devices and Monitoring
Penalty
Summary
Three residents did not receive care and treatment in accordance with physician orders, as observed through record review, staff and resident interviews, and direct observation. One resident with a history of left total knee arthroplasty, cellulitis, diabetes, and congestive heart failure (CHF) had orders for daily weights and edema assessments to monitor for fluid retention, as well as orders for the application and removal of TED hose and Tubigrip bandages. Staff failed to obtain and document daily weights on specific days and did not consistently perform or document edema assessments as ordered. Additionally, the resident did not have TED hose orders upon admission despite wearing them, and after an order change to Tubigrips, staff continued to use TED hose instead of following the updated order. Two other residents with diagnoses including CHF, atrial fibrillation, chronic kidney disease, muscle wasting, and vascular dementia had physician orders for Tubigrip stockings to be applied in the morning and removed in the evening. Observations and interviews revealed that staff did not consistently remove the Tubigrips at night as ordered, resulting in the residents wearing them overnight. Both residents and their representatives reported that staff sometimes forgot to remove the Tubigrips, and this was corroborated by staff interviews and direct observation. The facility lacked a written policy for the application and removal of TED hose and Tubigrip stockings, relying solely on medical orders. The Director of Nursing confirmed that staff did not follow the care plans and medical orders regarding daily weights, edema assessments, and the application and removal of compression devices for the affected residents.
Failure to Provide Necessary Respiratory Care and Documentation
Penalty
Summary
A resident with diagnoses including malignant neoplasm of the bladder, secondary neoplasm of the bone, toxic encephalopathy, and osteoporosis with pathological fractures was observed to have an oxygen concentrator at the bedside. The resident had moderate cognitive impairment and an activated Power of Attorney for Health Care. Despite requiring supplemental oxygen following a change in respiratory status, there was no physician order for oxygen therapy or a care plan addressing oxygen use in the resident's medical record at the time of the survey. Staff interviews confirmed uncertainty regarding the resident's oxygen use, and the CNA care plan did not include oxygen therapy. The Director of Nursing provided an undated oxygen policy focused on safety and fire prevention but confirmed the absence of a comprehensive oxygen therapy policy. During the survey, the DON located an order from the hospice provider for oxygen therapy, but it was only entered into the medical record during the survey process. Additionally, a standing order for emergency oxygen was also entered into the record during the survey. Prior to these entries, the resident's need for oxygen was not supported by a current order or care plan, and staff were not consistently aware of the resident's oxygen requirements.
Failure to Provide Timely Pharmaceutical Services Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident. The resident, who had diagnoses including left total knee arthroplasty, osteoarthritis, cellulitis, and diabetes, was admitted with intact cognition and was responsible for their own healthcare decisions. Physician orders were in place for D-Mannose, nateglinide, and pregabalin, with specific dosages and administration times. However, a review of the Medication Administration Audit Report revealed multiple instances where these medications were not administered as ordered due to unavailability. Specifically, D-Mannose, nateglinide, and pregabalin were missed on several occasions over a period of days, with documentation indicating the medications were not available at the facility at the required times. The facility's policy required medications to be administered safely, timely, and as prescribed, within one hour of the scheduled time unless otherwise specified. Despite this, the medications were not provided to the resident according to physician orders. During an interview, the Director of Nursing confirmed that the pharmacy is expected to deliver medications when ordered and that staff should contact the pharmacy with a stat order if medications are not delivered, indicating that the established procedures for obtaining medications were not followed in these instances.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the 400 North unit was observed left unlocked and unattended, with an open computer screen displaying resident information. The drawers of the cart faced the hallway, and a resident was seen self-propelling in a wheelchair nearby. The agency RN responsible for the cart confirmed that it should have been locked and the computer turned off, but stated they forgot to do so when leaving to refill a water jug. The facility's policy requires all medication storage compartments, including carts, to be locked when not in use and not left unattended if open or accessible. The DON also confirmed that medication carts should be locked when unattended.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at palatable, safe, and appetizing temperatures for four of six sampled residents. Multiple residents and a resident representative reported that hot and cold foods were not always served at appropriate temperatures, with some describing the food as cold, mushy, burned, or unpalatable. During meal observations, surveyors noted that food items such as sweet potatoes appeared burned and that several residents' meals contained blackened edges. Additionally, one resident reported that cold and hot foods were placed together under the same cover, resulting in cold food becoming warm and unappetizing. Temperature checks conducted by the surveyor revealed that food items on the steam table, including steamed rice, sweet and sour chicken, and broccoli, were held well below the required minimum hot holding temperature of 135°F. The dietary aide responsible for monitoring food temperatures was unaware of the minimum holding requirements or the necessary steps to take when temperatures were inadequate. The Food Service Director confirmed that while staff were expected to take holding temperatures prior to serving, temperatures were not routinely monitored at the end of meal service, and there were known issues with the steam rollers not maintaining proper temperatures.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Assess and Manage Pain During Night Shift
Penalty
Summary
A resident with diagnoses including COPD, congestive heart failure, anxiety disorder, and failure to thrive, who was cognitively intact and responsible for their own healthcare decisions, was not assessed for pain or provided pain medication during a specific night shift. The facility's policy required pain assessments and appropriate pain management based on comprehensive assessment and resident choice. The resident had physician orders for as-needed hydrocodone-acetaminophen and acetaminophen for pain, and a specific order for pain assessments every shift for three days. Review of the medical record showed that while pain assessments were documented for all other shifts, there was no pain assessment or administration of pain medication during the night shift in question. The resident later reported to staff that they did not receive pain medication that night, and the Medication Administration Record confirmed that the first dose of pain medication was given the following morning for severe pain. The Director of Nursing confirmed that the resident was not assessed for pain and did not receive pain medication during the identified night shift.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the accurate administration of medications for three residents. One resident with diabetes and end-stage renal disease self-administered Tresiba insulin without a physician's order or a self-administration assessment, and there was no care plan in place for self-administration. Additionally, a significant quantity of the resident's insulin was unaccounted for, and staff allegedly borrowed insulin from another resident's supply for administration, contrary to facility policy and safe medication practices. Another resident with multiple chronic conditions, including COPD, pulmonary embolus, and chronic pain, did not receive several doses of prescribed medications, including controlled substances and pain medications. The resident reported frequently having to request missing medications, and the medical record lacked documentation explaining whether the medications were administered, refused, or unavailable. The facility's medication administration policy was not followed, as staff failed to document missed doses or provide required progress notes. A third resident with moderate cognitive impairment and multiple serious diagnoses, including cirrhosis and chronic kidney disease, did not receive a scheduled Epoetin Alfa injection as ordered. The medication was withheld due to a missing hemoglobin level, but there was no order obtained for the necessary lab work, and the omission was not properly documented. These deficiencies were identified through observation, staff and resident interviews, and record review, and they demonstrate failures in medication administration, documentation, and adherence to facility policy.
Failure to Honor Resident Food Preferences for Breakfast
Penalty
Summary
The facility failed to honor the food preferences of two residents by not providing their preferred breakfast item of fried eggs, despite these preferences being documented and communicated to dietary staff. One resident, who was cognitively intact and had a history of chronic medical conditions, regularly requested fried eggs for breakfast but was repeatedly told by the dietary manager that shelled eggs could not be provided due to vendor supply issues and facility budget constraints. The resident expressed dissatisfaction with the alternative options, such as liquid eggs, and stated that discussions with the dietary manager had not resulted in their preference being met. Observations in the kitchen revealed that shelled eggs were present but reserved for specialty items, and not used to fulfill resident breakfast preferences. Another resident, with moderately impaired cognition and multiple chronic diagnoses, also had a documented preference for fried eggs at breakfast but did not receive them. This resident reported that requests for fried eggs were denied due to cost and availability, and expressed dissatisfaction with the alternative scrambled eggs provided. Interviews with dietary staff confirmed that while shelled eggs were ordered, they were not served to residents as requested due to budget limitations, vendor supply issues, and staffing constraints. Meal tickets for residents who preferred fried eggs were changed to "if available," but the facility did not provide the preferred item, resulting in unmet resident preferences.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a sanitary manner, which had the potential to affect all 69 residents. During a kitchen tour, it was observed that pre-cooked foods such as pureed vegetables, fish, macaroni and cheese, and others were stored without a cooling log. The Dietary Manager (DM) confirmed that these foods should have been cooled using an approved method and documented to ensure safe consumption. The facility's policy and the FDA Food Code require that cooked foods be cooled to specific temperatures within a set timeframe, but this was not adhered to. Additionally, the facility did not consistently monitor and document the temperatures of cooked foods. The cooking temperature logs for December 2024 and January 2025 were missing multiple entries for supper meals. The DM admitted to filling in missing temperatures after the fact and acknowledged that the process of documenting cooked food temperatures was not consistently followed by the PM staff. This lack of documentation and adherence to cooking temperature guidelines could compromise food safety. The facility also failed to properly use the three-compartment sink and sanitizer buckets. The sanitizer testing logs showed PPM levels above the required 200 for several days, and some logs were missing entries. The DM was unaware of the correct PPM levels and water temperature requirements for the sanitizing solution, indicating a lack of understanding among staff regarding proper sanitization procedures. This oversight in maintaining proper sanitization levels could lead to unsanitary conditions in food preparation areas.
Failure to Adhere to Prescribed Diet Orders and Serving Sizes
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to prescribed diet orders and serving sizes. This deficiency was observed in five residents, where residents on pureed diets did not receive the correct serving sizes for meals on specific dates. Additionally, residents on carb-controlled and low concentrated sweets diets did not receive their meals as ordered. For instance, one resident's meal ticket indicated they should receive double portions and specific diet items, but these were not provided during meal services. The surveyor observed several discrepancies during meal services, including the use of incorrect scoop sizes for serving pureed foods and desserts. Dietary aides were noted to serve full portions of desserts to residents on restricted diets and did not follow the specified serving sizes outlined in the diet spreadsheets. One resident was served a pork roast instead of the ground meat as per their diet order, and another resident expressed concerns about not receiving enough food, feeling weak and hungry as a result. Interviews with residents and dietary staff revealed that the facility did not have enough servings to meet residents' requests for more food, and there was a lack of adherence to the diet spreadsheets that guide meal preparation and serving sizes. The dietary manager confirmed that all staff have access to these spreadsheets, which are intended to ensure compliance with diet orders, but the recommended scoop sizes were not consistently used during meal service.
Failure to Obtain Court-Ordered Protective Placement for Resident with Guardian
Penalty
Summary
The facility failed to ensure that a court-ordered protective placement was obtained for a resident with a legal guardian, as required by state statute. The resident, who had a legal guardian since 2006 and a successor guardian appointed in 2023, was admitted to the facility from a group home. Despite the requirement for protective placement documentation for residents with guardians whose stay exceeds ninety days, the facility did not have such documentation in the resident's medical record. During the survey, the Nursing Home Administrator was unable to provide the necessary protective placement paperwork, and the Social Worker acknowledged that the facility had not obtained it. The Social Worker indicated that the Admissions Coordinator is responsible for obtaining the paperwork upon admission, and the Social Worker ensures annual reviews are received from the county. However, the facility did not have a policy regarding protective placement, and the Social Worker admitted that they had contacted the county to initiate the process only after the surveyor's inquiry.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide three residents with the necessary Medicare coverage and liability notices, specifically the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) and the Notice of Medicare Non-Coverage (NOMNC) forms, in a timely manner. Residents R13, R15, and R168 did not receive these forms when their Medicare services ended, and there was no documentation to confirm that the forms were delivered or that the residents or their representatives were informed. The facility's process involved leaving forms in residents' rooms or sending them via mail, but there was no system to track whether the forms were actually sent or received. Additionally, the facility lacked a policy regarding the issuance of Medicare coverage/liability notices. Interviews with the residents and their representatives revealed that they were not verbally informed about the termination of Medicare services, nor did they receive the forms by mail. The Minimum Data Set Coordinator (MDSC) responsible for distributing these forms could not provide evidence of their delivery. The Nursing Home Administrator acknowledged that notifications should be mailed and documented, but this was not done. The absence of a formal policy and documentation process contributed to the deficiency, leaving residents uninformed about their Medicare coverage status and potential financial liabilities.
Privacy Breach During Resident Showers
Penalty
Summary
The facility failed to ensure privacy for a resident during shower times, leading to a deficiency in maintaining confidentiality and dignity. The resident, who has intact cognition and is responsible for their healthcare decisions, reported that staff frequently entered the shower room while they were showering, despite a grievance being filed. The resident had a sign created to indicate when they were using the shower, but staff were not adequately informed about the sign, resulting in continued interruptions. Observations and interviews revealed that the shower room was communal, with linens stored in a closet within the room, which contributed to staff entering during the resident's shower time. Some staff members were aware of the need for privacy and attempted to respect it by knocking and asking for permission to enter, while others admitted to entering the room accidentally. The Director of Nursing acknowledged that not all staff had been educated about the new privacy sign, and there was no documentation of staff education regarding this matter.
Deficiency in Providing Safe Water Temperatures
Penalty
Summary
The facility failed to ensure the provision of safe and comfortable water temperatures for two residents, R7 and R16, among 23 sampled residents. R7, who has intact cognition and is responsible for their healthcare decisions, reported multiple instances of not having warm water while showering on the fourth floor. The issue was attributed to high hot water usage by the laundry and kitchen, with a resolution expected by August 2025. R16, also with intact cognition, experienced a bath with cool water, which was against their care plan that advised avoiding exposure to extreme temperatures. The facility's grievance records showed several complaints about cold water, with the latest grievance indicating a 13-minute wait for warm water. Staff interviews revealed that the facility's hot water supply was insufficient, especially when multiple residents used it consecutively. CNA-O confirmed running out of warm water during a bath for R16 and rinsing them with cool water. CNA-T and RNM-L acknowledged the recurring issue, with RNM-L receiving weekly complaints in late 2024. Despite some staff education on water usage, the problem persisted, and the Nursing Home Administrator was unaware of the ongoing issues, believing the problem had been resolved.
Failure to Resolve Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance filed by a family member of a resident, identified as R25, regarding the delay in obtaining lab culture results. R25 had a lab culture obtained, and over several days, the family member repeatedly contacted the facility for the results but was not provided with them. The family member filed a grievance, but the facility only informed them that the issue was resolved without providing an explanation or details on the resolution. R25 was admitted to the facility with diagnoses including T12 compression deformity, chronic kidney disease, and anemia, and had intact cognition as indicated by a BIMS score of 13 out of 15. The facility's grievance policy requires prompt resolution and communication with the resident or their representative, which was not adhered to in this case. The Nursing Home Administrator and Director of Nursing acknowledged the grievance and mentioned a process change to prevent future delays, but there was no documentation of this change or staff education.
Failure to Individualize Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with impaired skin integrity and multiple wounds. The resident, who was bed bound and receiving hospice services, had a pressure-relieving air mattress that was incorrectly set to 360 pounds, despite the resident's actual weight being 180 pounds. This incorrect setting was not individualized in the resident's care plan, which lacked specific instructions for the air mattress settings. The resident's medical record indicated multiple diagnoses, including pressure-induced deep tissue injury, chronic venous ulcers, and a chronic ulcer of the buttocks. The facility's Wound Care Prevention and Program Management policy required interventions to be documented and individualized based on risk factors, but this was not adhered to in the resident's case. Interviews with the Director of Nursing and a Registered Nurse Manager confirmed the air mattress was set incorrectly, highlighting a failure to follow the facility's policy and provide necessary individualized care for the resident's condition.
Failure to Prevent Catheter-Associated UTIs
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for two residents, R15 and R368. R15, who has severe cognitive impairment and a history of a recent UTI, was observed multiple times with an uncovered catheter bag placed on the floor underneath their wheelchair. This was noted in the dining area and hallway over a span of three days. The facility's policy, dated 9/2014, clearly states that catheter bags should be kept off the floor to prevent catheter-associated urinary tract infections. Similarly, R368, who has intact cognition and is on enhanced barrier precautions, was observed with an uncovered catheter bag in contact with the floor under their bed. Despite the presence of a sign indicating enhanced barrier precautions, the catheter bag was not managed according to the facility's policy. The Director of Nursing confirmed that catheter bags should be covered and off the floor, indicating a lapse in adherence to the established procedures designed to prevent infections.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of drugs for three residents. Resident 7 did not receive eight doses of scheduled medication due to unavailability. This resident, who had intact cognition and was responsible for their healthcare decisions, expressed frustration over the recurring issue of medication shortages, particularly with their pain medication, OxyContin. The facility staff attempted to address the issue by contacting the resident's provider and the facility's Medical Director, but the problem persisted, leading to missed doses of several medications. Resident 114, who had severe cognitive impairment, did not receive a scheduled dose of Depakote ER because the medication was not crushable, and the alternative form, Depakote sprinkles, was not available. The LPN preparing the medication confirmed the unavailability and the inability to administer the prescribed medication at the scheduled time. This issue was acknowledged by the nursing staff, who had requested the alternative form from the pharmacy but had not received it in time. Resident 15, with moderate cognitive impairment, was administered an expired medication by an LPN. The LPN dispensed an expired iron tablet and disposed of it improperly in a garbage bin on the medication cart. The facility's policy required medications to be disposed of in a Drug Buster, but the LPN confirmed that non-narcotic medications were typically disposed of in the garbage bin. This improper disposal practice was confirmed by the RNM and DON, who acknowledged that medications should not be disposed of in the garbage bin on the medication cart.
Delay in Laboratory Services Leads to Treatment Delay
Penalty
Summary
The facility failed to ensure prompt laboratory services for a resident, identified as R25, which resulted in a delay in starting necessary antibiotic treatment. R25, who had intact cognition and was responsible for their healthcare decisions, had an order for a wound culture to be completed on January 2, 2025. The culture was collected on the same day but was not sent to the laboratory until January 4, 2025. The laboratory subsequently informed the facility on January 5, 2025, that the culture could not be used because it was not processed in a timely manner. Consequently, a second culture had to be obtained on January 5, 2025, and sent to the lab. The delay in processing the initial culture led to a postponement in diagnosing the infection and starting the appropriate antibiotic therapy. The culture results, which were finally obtained on January 8, 2025, indicated the presence of Escherichia coli and staph, prompting the provider to order antibiotic treatment. Interviews with the Registered Nurse Managers and the Director of Nursing confirmed that the initial culture was not picked up timely, which directly contributed to the delay in treatment for R25.
Failure to Provide Prescribed Medication to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R1, who was admitted with a prescription for Vyvanse. R1 did not receive the prescribed medication from 11/9/24 through 11/11/24 due to a series of communication and procedural failures. Upon admission, the hospital provided two scripts for R1, but not for Vyvanse. The prescriber attempted to send a Vyvanse script to the pharmacy on 11/8/24, but it did not go through, and the facility was not informed. Over the weekend, R1's family brought Vyvanse from home, but it was not in the original container, so staff could not administer it. Consequently, R1 did not receive the medication, leading to increased anxiety and upset. Interviews with staff revealed that there was a lack of follow-up to ensure the medication was obtained from the pharmacy. RN-E, who assisted with R1's admission, confirmed that the Vyvanse script was expected but not received, and RN-F noted that the pharmacy did not send the medication over the weekend. The Nursing Home Administrator acknowledged the communication breakdown between the provider and the pharmacy but could not provide documentation of any staff education related to the incident. R1, who was responsible for their own healthcare decisions, was discharged against medical advice shortly after the incident.
Failure to Provide Prescribed Double Entree for Resident
Penalty
Summary
The facility failed to meet the nutritional needs of a resident who had an order for double entree portions at all meals to aid in wound healing. The resident, who had diagnoses including dementia, a laceration on the left great toe, and a stage 3 pressure ulcer, was observed not receiving the prescribed double entree during a lunch meal. The resident's medical record clearly indicated the need for double entrees at all meals, which was not adhered to during the observed meal. The deficiency was identified during an observation where a dietary aide served the resident a single entree despite the meal ticket indicating a double portion was required. The dietary aide was unsure why the resident did not receive the double entree. The Food Safety Manager confirmed the oversight and acknowledged the need for training, indicating that the resident should have received the therapeutic diet as ordered.
Failure to Prevent Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident, identified as R1, who was subjected to inappropriate sexual behavior by another resident, R2. During the night shift, an LPN observed R2 attempting to kiss another resident, R6, and documented the incident. However, no interventions were implemented to prevent further incidents. Subsequently, an RN observed R2 engaging in inappropriate behavior with R1, who was unable to consent due to severe cognitive impairment. This incident was not immediately addressed with appropriate supervision or interventions. R2 had a history of sexually inappropriate behavior, including making inappropriate comments and touching staff, which was documented in nursing notes prior to the incident with R1. Despite this history, R2 was not placed under increased supervision until after the incident with R1. The facility's policy on abuse prevention was not effectively implemented, as there was a lack of timely intervention and supervision for R2, who had severe cognitive impairment and a history of inappropriate behavior. The facility's failure to supervise R2 and protect other residents from potential abuse led to a finding of immediate jeopardy. The deficiency was identified when the surveyor reviewed the facility's records and interviewed staff, revealing that the facility did not take adequate measures to prevent further incidents after R2's initial inappropriate behavior. The facility's inaction in addressing R2's behavior and ensuring the safety of other residents contributed to the deficiency.
Removal Plan
- Placed R2 on 1:1 supervision and moved R2 to a different unit.
- Initiated facility-wide education on abuse and 1:1 supervision.
- Completed psychosocial interviews with R1, R2, and R6.
- Updated R1, R2, and R6's care plans.
- Notified R1, R2, and R6's physicians, representatives, and local law enforcement.
- Interviewed residents and staff and initiated monitoring for changes in behavior of non-interviewable residents.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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