Sauk Co Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Reedsburg, Wisconsin.
- Location
- 1051 Clark St, Reedsburg, Wisconsin 53959
- CMS Provider Number
- 525114
- Inspections on file
- 17
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Sauk Co Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities developed an open area on the left fifth finger that staff documented only as an "open area" and later as a "small wound" and "blood blister," without completing an initial comprehensive wound assessment or ongoing detailed wound measurements and characteristics. Over several days, nurses recorded that wound care was done per order, but there was no systematic documentation of wound status, and a noted change when the fingernail appeared to be falling off was not accompanied by a thorough assessment or physician notification in the record. The finger subsequently became swollen, red, warm, and developed a large hematoma, prompting transfer to the ED, where an abscess with purulent drainage and a possible nondisplaced fracture of the distal phalanx were identified, and later imaging review was consistent with osteomyelitis. Surveyors confirmed the absence of incident reporting and weekly wound assessments, and leadership acknowledged that wound assessments were not performed for this area.
A resident with severe dementia and significant medical comorbidities developed a large, red, warm hematoma with drainage on the left pinky, was sent to the ER, and was diagnosed with an abscess and a closed nondisplaced fracture of the distal phalanx. Facility policy required immediate investigation and reporting of injuries of unknown origin, with specific timeframes for serious and nonserious injuries, but staff did not complete an incident report, did not perform weekly wound assessments, and did not report the unexplained fracture to the state as required. During the survey, an LPN stated she did not know how the finger was broken, and the administrator acknowledged that this injury of unknown source should have been reported and investigated, confirming the failure to follow abuse/neglect reporting procedures.
A resident with severe dementia and multiple comorbidities developed a large, red, warm hematoma with pus drainage on the left pinky, leading to transfer to the ER where imaging showed a closed nondisplaced fracture of the distal phalanx and an abscess. Facility policy required prompt, thorough investigation and reporting of injuries of unknown origin, including completion of incident reports and caregiver misconduct reports within specified time frames. An LPN later stated the finger had been broken and osteomyelitis found but did not know how the injury occurred. When the surveyor requested documentation, the DON reported there was no incident report or weekly wound assessment, and the administrator acknowledged that such an injury should have been reported and investigated, demonstrating the facility’s failure to follow its abuse/neglect and injury-of-unknown-source procedures.
Two residents with severe cognitive impairment were involved in incidents where a staff member allegedly used threatening and demeaning language. Although the incidents were reported internally and the alleged perpetrator was removed from duty, the facility failed to notify the State Survey Agency within the required timeframe, as mandated by policy and regulation.
Two residents with severe cognitive impairment were involved in an alleged verbal abuse incident by a CNA. The facility did not conduct a thorough investigation, failed to interview the residents, did not remove the accused CNA from duty during the investigation, and did not report the allegation to the state agency within the required timeframe. The investigation relied mainly on staff statements and a skin check, without ensuring resident safety as per facility policy.
A resident at a LTC facility developed a stage 3 pressure injury due to inadequate care and failure to prevent pressure ulcers. Despite being at risk, the facility continued using a slide board transfer, contributing to the injury. The facility did not properly identify or stage the pressure injury and failed to provide alternative transfer methods or document risk versus benefits discussions. The resident's condition deteriorated, leading to infection and requiring an EpiFix graft.
Surveyors found expired medications in a facility, including Loperamide, Escitalopram, Naproxen, insulin pens, and Promethazine suppositories. Staff were unaware of expiration dates due to missing labels and had to contact the pharmacy for confirmation. The DON acknowledged the issue, indicating a gap in medication management.
The facility failed to conduct a complete background check for an LPN, as required by its policies. The LPN, who had lived outside of Wisconsin in the past three years, was hired without an out-of-state criminal background check. This oversight was acknowledged by the Nursing Home Administrator, indicating a lapse in following procedures to prevent abuse, neglect, and theft.
A resident with a catheter was not provided appropriate care to prevent urinary tract infections due to inadequate hand hygiene by a CNA. The CNA failed to change gloves and perform hand hygiene after catheter care and before assisting the resident with their gait belt and clothing, contrary to the facility's policy. Both the CNA and DON acknowledged the lapse in following proper procedures.
A facility was found to have a medication error rate of 6.9%, exceeding the acceptable 5% threshold. Two residents were affected when medications were not administered at the ordered times. One resident did not receive her prescribed senna on time, and another received aspirin earlier than scheduled. The errors were acknowledged by the LPNs involved and confirmed by the DON.
A resident with a history of dementia and chronic kidney disease experienced a significant change in condition, including decreased appetite, abdominal pain, and lethargy. Despite these symptoms, the facility failed to conduct a comprehensive assessment or notify the physician, leading to the resident's hospitalization for a perforated colon and pneumoperitoneum. This oversight resulted in immediate jeopardy due to the facility's failure to provide care consistent with professional standards.
A resident in a LTC facility suffered multiple fractures after CNAs attempted to remove an incontinent product while the resident was seated in a shower chair, causing a fall. The CNAs moved the resident without a nurse's assessment, violating facility policy. The resident sustained a right tib/fib fracture and later an undetected left femur fracture, leading to hospitalization. The facility's failure to follow fall prevention procedures resulted in immediate jeopardy.
A resident with Atrial Fibrillation on Coumadin was prescribed Bactrim, which potentiates Coumadin. The facility failed to monitor the resident's INR, resulting in a critically high INR of 4.5. The facility did not inform the physician or anticoagulation clinic about the Coumadin therapy, leading to inadequate monitoring and increased risk of bleeding.
The facility did not consistently follow professional standards of practice in preventing and treating pressure injuries for a resident with nonverbal vascular dementia, severe Peripheral Arterial Disease, and other conditions. Observations revealed lapses in regular repositioning, poor hand hygiene during wound care, and failure to offload heels as ordered. Additionally, pain management during wound care was inadequate, and there was a lack of proper documentation and communication with the Medical Doctor regarding changes in wound status. These deficiencies contributed to the development and infection of a stage 4 pressure injury.
The facility failed to ensure that diabetic residents received daily foot checks as required by current standards of practice. Four residents with diabetes did not have daily foot checks documented in their care plans or physician orders. Interviews with nursing staff revealed that foot checks were performed weekly or bi-monthly, rather than daily.
The facility failed to serve food at appropriate temperatures, affecting four residents. Observations and interviews revealed that hot food was not always served hot and cold food was not served cold. A test tray confirmed these issues, and the Dietary Manager acknowledged the problem.
Failure to Assess and Monitor Finger Wound Leading to Abscess and Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care and monitoring in accordance with professional standards of practice and its own wound policy for a resident with severe cognitive impairment and multiple comorbidities. On 12/10/25, staff observed and documented an open area on the resident’s left fifth digit, noting only that the left hand pinky had an open area reported to the supervisor. No initial comprehensive wound assessment was completed at that time, and there was no documentation of wound measurements, size, or characteristics as required by the nursing process and by wound assessment best practices. The facility’s care plan identified the resident as at risk for impaired tissue integrity and directed nurses to inspect skin and assess skin status, but the documentation for this new wound remained limited to brief notes that treatment was done per order. On 12/11/25, the physician ordered cleansing of a scab on the left pinky with soap and water and application of betadine, to be left open to air. Over the following days, progress notes repeatedly documented that wound treatment was done per order or that there was “wound care to left pinky as ordered,” without any detailed wound assessments, measurements, or descriptions of wound bed, edges, exudate, peri-wound skin, or pain. A weekly skin assessment on 12/15/25 described the skin as within normal limits with a small wound to the left pinky being treated, but again did not include a thorough wound assessment. Later on 12/15/25, staff documented that the left pinky nail appeared to be falling off with no signs or symptoms of infection, but there was no documented comprehensive assessment of this change and no physician notification recorded in the resident’s record. From 12/10/25 through 12/19/25, there is no documentation of systematic wound assessments to indicate that staff were monitoring the wound for decline or improvement. On 12/19/25, staff noted a change in the wound appearance and reported that the left pinky was cleaned as ordered and the charge nurse was notified. Later that day, documentation described a large hematoma on the lateral aspect of the left pinky, red and warm, and the POA and on-call physician were contacted, resulting in transfer to the emergency department. In the ED, the left pinky was found to be quite swollen with purplish discoloration and purulent drainage, and the resident was diagnosed with an abscess and a possible nondisplaced fracture of the distal phalanx. Subsequent evaluations, including review of radiographs and consultation, identified erosive bone loss of the fifth distal phalanx consistent with osteomyelitis, and the NP stated that bacteria likely entered through the open area. The surveyor found no incident report, no weekly wound assessment documentation, and no evidence of wound monitoring or assessment between the initial finding of the open area and the development of the hematoma and abscess, and facility leadership acknowledged that wound assessments were not completed for what they characterized as a blood blister or hematoma.
Failure to Timely Report Injury of Unknown Origin Involving Finger Fracture
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin, later identified as a closed nondisplaced fracture of a resident’s left pinky finger, to the State Survey Agency as required by policy and regulation. The facility’s written policy on Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation states that all allegations of abuse, neglect, mistreatment, injuries of unknown source, or misappropriation of property must be promptly investigated and reported to appropriate agencies in accordance with state and federal laws. The policy further specifies that serious injuries must be reported to law enforcement no later than two hours after discovery and nonserious injuries no later than 24 hours after discovery, and that injuries of unknown origin are to be treated as potential misconduct requiring immediate reporting and investigation. The resident involved had significant medical and cognitive impairments, including cerebrovascular disease, unspecified severe dementia with anxiety, and bilateral osteoarthritis of the hips. A Significant Change MDS dated 1/22/26 documented severe cognitive impairment with a BIMS score of 00, indicating the resident was unable to reliably report or explain events. On 12/19/25, nursing documentation noted a change in the appearance of the resident’s left pinky finger, including a large, red, warm hematoma on the lateral aspect of the finger. The POA and on-call physician were notified, and the resident was transferred to the emergency department for evaluation of the hematoma and possible abscess. Hospital records from that same day documented that the resident presented with hand pain and a swollen left pinky with purulent drainage, with the source of injury unclear. Radiologic imaging showed a possible nondisplaced fracture of the distal phalanx of the left little finger, and the discharge diagnosis included an abscess and a closed nondisplaced fracture. During the survey, an LPN reported that the finger had been broken about a month earlier and that she was not aware of how the fracture occurred, and the DON confirmed there was no incident report or weekly wound assessment documentation for the injury. The Nursing Home Administrator acknowledged in interview that an injury of unknown source should be reported to the state and that this resident’s fracture should have been reported and investigated to determine the cause, but this was not done within the required timeframe, resulting in the cited deficiency.
Failure to Investigate Injury of Unknown Origin and Follow Abuse/Neglect Reporting Policy
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin and to respond in accordance with its abuse/neglect and injury-of-unknown-source policies. The facility’s written policy, dated 12/2025, requires that all allegations of abuse, neglect, mistreatment, injuries of unknown source, and resident rights violations be promptly and thoroughly investigated, with immediate measures taken to ensure resident safety, timely reporting to the administrator and appropriate agencies, and completion of a Caregiver Misconduct Incident Report within five working days. The policy also defines injuries of unknown origin as those where the source is not observed or cannot be explained by the resident and is suspicious due to extent, location, or pattern of injuries, and outlines specific investigative steps such as interviewing staff and residents and reviewing prior shifts. The resident involved was admitted with multiple significant medical conditions, including cerebrovascular disease, severe unspecified dementia with a BIMS score of 00, anxiety, and bilateral hip osteoarthritis. Progress notes show that on 12/19/25, staff documented a change in the resident’s left pinky finger, initially noting skin problems and later describing a large, red, warm hematoma on the lateral aspect of the finger. The resident’s POA and on-call physician were notified, and the resident was transferred to the emergency department that evening. Hospital records from that visit document that the resident presented with hand pain and a swollen left pinky with pus drainage, with the history noting it was unclear whether there had been an associated injury. Diagnostic imaging at the hospital identified a possible closed nondisplaced fracture of the distal phalanx of the left little finger, along with an abscess. During a subsequent surveyor interview, an LPN reported that the finger had been broken about a month earlier, that osteomyelitis had been found, and that the resident’s left hand was contracted, requiring staff to pull the fingers up to apply palm protectors, but the LPN was not aware how the fracture occurred. When the surveyor requested an incident report and weekly wound assessments related to the injury, the DON stated there was no incident report and no weekly wound assessment documentation. In a separate interview, the administrator acknowledged that an injury of unknown source should be reported to the state and that the resident’s finger fracture should have been investigated to determine its cause, confirming that the required investigation and reporting processes were not carried out.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by policy and regulation. The deficiency involved two residents with severe cognitive impairment, both of whom were involved in incidents where a staff member allegedly used threatening and demeaning language. The facility became aware of these allegations but did not report them to the State Agency within the required timeframe. One resident with vascular dementia reported to a surveyor that staff yelled at her often, which made her feel not good. A Certified Nursing Assistant (CNA) observed another CNA being reckless with residents and overheard the staff member threaten to "beat your butt" to a resident. The CNA reported the incident to a nurse and the Director of Nursing (DON), expressing concern for her own safety and requesting police involvement. The DON sent the alleged perpetrator home and notified the Nursing Home Administrator (NHA), but the incident was not reported to the State Agency. Another resident with Alzheimer's Disease and metabolic encephalopathy was also involved in the incident. The NHA and DON both acknowledged that the incident constituted an allegation of abuse and that it should have been reported to the State Agency within two hours. However, the NHA decided not to report the incident after conducting an internal investigation and determining that witness statements varied and one CNA would not provide a statement. Despite facility policy requiring immediate reporting and investigation, the required notification to the State Agency did not occur.
Failure to Thoroughly Investigate and Protect Residents During Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving two residents with severe cognitive impairment. The incident was reported to the Director of Nursing (DON) by a CNA who overheard another CNA making threatening statements to residents, including threats to 'slap' and 'beat' them. The DON notified the Nursing Home Administrator (NHA), who arrived at the facility, spoke with staff, and requested written statements. However, the investigation did not include interviews with the residents involved, despite their cognitive impairments, and relied primarily on staff statements and a skin check conducted the following morning. The facility's policy requires immediate intervention to ensure resident safety, including removing the alleged perpetrator from the facility and suspending them from duties during the investigation. Although the accused CNA was initially sent home, records show that the CNA continued to work at the facility on subsequent days while the investigation was ongoing. This failure to remove the accused staff member from resident care duties meant that resident safety was not ensured during the investigation period. Additionally, the facility did not report the abuse allegation to the state agency within the required two-hour timeframe, as acknowledged by both the NHA and DON during interviews. The investigation was incomplete, lacking resident interviews and timely reporting, and did not fully adhere to the facility's own abuse investigation and reporting policies. The documentation provided by the facility included staff education and signature sheets, but did not demonstrate a comprehensive or timely response to the abuse allegation.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate care to prevent pressure ulcers for a resident identified as R19, who was at risk due to decreased mobility, bilateral above-knee amputation, and radiation therapy. R19 developed a facility-acquired stage 3 pressure injury (PI) that was not properly identified or staged by the facility. Instead, the facility considered it a chronic wound caused by friction and shearing from the use of a slide board transfer. Despite recognizing these risk factors, the facility continued to use the slide board and did not document any risk versus benefits discussion with R19 regarding its continued use. R19's medical history included prostate cancer, heart disease, venous insufficiency, and peripheral vascular disease, among others. The resident's care plan included the use of a Roho cushion and repositioning every two hours to prevent skin breakdown. However, there were delays in obtaining the Roho cushion, and R19 was observed using a rolled washcloth under his hip, which contributed to the PI. The facility did not provide alternative transfer methods to the slide board or adequately educate R19 on the risks associated with its use, leading to the deterioration and infection of the PI, which eventually required an EpiFix graft. The facility's failure to appropriately stage the PI and provide alternative transfer methods resulted in immediate jeopardy. The wound physician had identified the wound as a stage 3 pressure injury, but the facility did not classify it as such. The facility's inaction and lack of documentation regarding risk versus benefits discussions contributed to the development of two facility-acquired pressure injuries for R19, with the left ischial tuberosity deteriorating and becoming infected.
Removal Plan
- R19 was educated on Risks vs Benefits regarding use of the slide board and placing barrier on top of pressure relieving device which decreases effectiveness.
- Resident was consistently refusing interventions including, but not limited to, nutritional supplements, attending scheduled appointments regularly, participating in therapy and following recommendations of using Hoyer Lift instead of the slide board. This was also included in his Risks vs Benefits education.
- Nursing staff was educated regarding: Prevention of Pressure Injury, including: A. Pressure Points, Shearing, Friction and Proper Positioning. B. What to look for regarding what interventions are working and what are not.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional practices, leading to the presence of expired medications in the facility. During the survey, it was observed that several medications, including Loperamide, Escitalopram, Naproxen, insulin pens, and Promethazine suppositories, were expired and still in circulation. The surveyor noted that medication carts and storage rooms contained these expired drugs, which were not removed or returned to the pharmacy as required by the facility's policy. Interviews with nursing staff revealed a lack of awareness regarding the expiration dates of medications, as some medication cards did not display expiration dates, and staff were unsure of how to determine them. The staff had to contact the pharmacy to confirm expiration dates, indicating a gap in the facility's medication management system. The Director of Nursing was informed of the expired medications, acknowledging that they should not have been in circulation, and indicated that education for the nursing staff was underway.
Failure to Conduct Complete Background Check for LPN
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse, neglect, and theft, as evidenced by the lack of a complete background check for an LPN hired by the facility. The facility's policy on Prevention/Reduction of Resident Abuse, Neglect, Exploitation, or Misappropriation of Property requires a criminal background check for all prospective employees. Additionally, the Care Giver Background Investigations policy mandates obtaining out-of-state conviction records if a caregiver has lived outside the state in the last three years. However, the facility did not conduct an out-of-state criminal background check for an LPN who had resided outside of Wisconsin within the last three years. The deficiency was identified during a surveyor's review of the LPN's background check information, which revealed the absence of an out-of-state criminal background check. The Nursing Home Administrator acknowledged that the facility did not complete the required out-of-state background check for the LPN, despite the facility's policies clearly stating the necessity of such checks. This oversight indicates a failure to adhere to established procedures designed to ensure the safety and well-being of residents by thoroughly vetting potential employees.
Inadequate Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure appropriate catheter care and hand hygiene for a resident, identified as R25, who was at risk for urinary tract infections. R25, who is cognitively intact and has a history of urinary retention and obstructive uropathy, was observed receiving catheter care from CNA H. During this process, CNA H did not change gloves or perform hand hygiene after completing catheter care and before handling the resident's gait belt and clothing. This action was contrary to the facility's hand hygiene policy, which requires hand washing or the use of alcohol-based hand rubs before and after direct contact with residents and after handling waste materials. The deficiency was further highlighted during an interview with CNA H, who acknowledged the failure to perform hand hygiene and glove changes as required. The Director of Nursing (DON B) also confirmed that hand hygiene and glove changes should have been performed between catheter care and assisting the resident with their clothing and mobility. This oversight in following proper infection control procedures could potentially contribute to the spread of infections, particularly given the resident's susceptibility due to their medical conditions.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility was found to have a medication error rate of 6.9%, exceeding the acceptable threshold of 5%. This was determined through observation, interview, and record review during a medication pass task involving seven residents. Two errors were identified among 29 opportunities, affecting two residents. The errors involved the failure to administer medications at the ordered times, which is a violation of the facility's medication administration policy. The first error involved a resident with a history of hemiplegia and hypertensive heart disease, who did not receive her prescribed senna at the scheduled time. The Licensed Practical Nurse (LPN) responsible for administering the medication mistakenly believed she had given it and signed it off as administered. Upon being informed of the oversight, the LPN acknowledged the error and suggested administering the medication at a later time, which deviated from the prescribed schedule. The second error involved another resident with hypertensive heart and kidney disease, who received aspirin at the wrong time. The aspirin was ordered to be given at bedtime, but the LPN administered it earlier in the day. The LPN admitted to noticing the error but proceeded with the administration regardless. The Director of Nursing confirmed that both instances were medication errors, as the medications were not administered at the ordered times.
Failure to Recognize and Respond to Change of Condition
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice for a resident who experienced a significant change in condition. The resident, who had a history of dementia, chronic kidney disease, and other health issues, presented with symptoms including decreased appetite, abdominal pain, fatigue, nausea, and vomiting. Despite these symptoms, the facility did not complete a gastrointestinal/abdominal assessment or notify the resident's physician about the abdominal pain. This oversight led to the resident becoming lethargic and eventually being transferred to the hospital, where a perforated colon and pneumoperitoneum were diagnosed. The nursing staff and CNAs observed changes in the resident's condition, such as a distended abdomen, decreased appetite, and lethargy, but failed to take appropriate action. Interviews with staff revealed that the resident's symptoms were reported to nurses, but there was no evidence of a comprehensive nursing assessment being completed. The facility's policy required immediate notification of the physician and documentation of any acute change of condition, but these steps were not followed. The lack of timely assessment and communication with the physician resulted in a delay in addressing the resident's deteriorating condition. The resident was eventually transferred to the hospital with severe symptoms, including hypotension and altered mental status, and was found to have a small bowel obstruction and bowel perforation. The facility's failure to recognize and respond to the resident's change of condition created a situation of immediate jeopardy, highlighting a significant deficiency in the care provided.
Removal Plan
- DON and ADON did a complete facility wide sweep to determine if any residents had a COC.
- Any residents identified with a COC had an immediate nursing assessment completed and MD/POA updated.
- DON and ADON reviewed the 24-hour report to confirm accuracy and to identify any other residents with a potential COC.
- DON educated nursing staff and reiterated the importance of completing accurate nursing assessments and documentation in a timely manner.
- Education on what to include in a thorough GI/digestive assessment and how to interpret the results.
- If assessment is abnormal, following with COC protocol including MD/POA notification.
- All staff received immediate education prior to their next working shift on Change of Condition, Nursing Documentation/Assessment, MD/POA Notification, 24-hour report should be brought to morning clinical meeting and afternoon stand down.
- 24-hour reports should include, but are not limited to: resident COC, follow up assessments, negative behaviors, pressure injuries, falls, resp/GI symptoms admissions, discharges, room changes, appointments, MD rounds, new orders, care plan changes, medication changes, therapy updates, refusals, change in functional and cognitive status.
- Audits will be completed on all the above items. Findings will be presented at least quarterly at QAPI.
- Nurses and CNAs were given Skills Assessment sheets to determine what area of focus is needed to perform job duties effectively.
- DON and/or ADON will review Assessment sheets, educate.
Inadequate Supervision Leads to Resident's Fall and Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident, leading to a fall and subsequent injuries. On September 2, 2024, a resident was in the shower room when a CNA attempted to remove an incontinent product while the resident was seated in a shower chair. This action caused the resident to begin to fall, and the CNAs assisted the resident to the floor. However, the CNAs moved the resident without a nurse's assessment, which is against the facility's fall policy. As a result, the resident sustained a fracture to the right tibia and fibula. Following the initial incident, the resident was not properly assessed for further injuries, leading to a delay in identifying a left femur fracture. The fracture was discovered later when the resident was sent to the hospital due to an open fracture of the left femur. The facility's failure to follow proper procedures for fall assessment and supervision resulted in significant harm to the resident, including multiple fractures and the need for hospitalization. The facility's policy on fall prevention and accident procedures was not adhered to, as evidenced by the CNAs' actions and the lack of immediate nursing assessment. The incident highlighted deficiencies in staff training and adherence to safety protocols, which contributed to the resident's injuries. The facility was found to be in immediate jeopardy due to these failures, which posed a serious risk to the resident's health and safety.
Removal Plan
- DON and ADON did a complete facility wide audit on transfer status of all residents to confirm accuracy on the care card.
- Resident care plans were reviewed for transfer status and ensured accuracy.
- All staff received immediate education on transfers and falls.
- Reviewed transfer policy and procedure and will present to all staff.
- Always follow care card on how to transfer resident.
- Always use a gait belt when transferring resident.
- Always use 2 people for Hoyer transfer.
- Do not bump arms/legs during transfer.
- Do not attempt to remove garments resident is sitting on or pull on the garments a resident is sitting on.
- Take time to ensure resident is ready for transfer into shower chair, all articles of clothing are off. If not, use safe transfer method to stand up or lay resident down.
- Always report to nurse if resident is not tolerating current transfer method.
- Reviewed facility fall policy and procedure and will present to all staff.
- If resident falls, activate emergency cord and if no response, call out.
- DO NOT move resident until an RN assesses for injury.
- RN to complete fall assessment including neurological and body assessment with vitals.
- If injury, update MD and call 911 to send to hospital for evaluation if ordered.
- Update: POA, DON/ADON, Administrator.
- Reviewed COC policy and procedure and will discuss with all nursing staff on recognition of COC and MD Notification.
- CNA's report any and all skin changes to your nurse immediately.
- Nurse assess skin and document with measurements.
- Update DON and Wound Nurse.
- Update MD and POA.
- Audits will be completed on all of the above items. Findings will be presented at least quarterly at QAPI.
- The facility will begin auditing resident transfers.
- All falls will be audited for the following: Root Cause identification MD Notification; POA/Family Notification, if applicable, Care Plan updated, RN Assessment done.
Failure to Monitor Drug Interactions Leads to High INR
Penalty
Summary
The facility failed to adequately monitor a resident's drug regimen, leading to adverse consequences. The resident, who had a diagnosis of Atrial Fibrillation and was on Coumadin, was prescribed Bactrim, an antibiotic known to potentiate the effects of Coumadin. The facility did not complete the necessary monitoring for symptoms of drug interactions, which resulted in the resident being sent to the hospital with a supratherapeutic INR of 4.5, significantly higher than the therapeutic range of 2-3. The facility's policy on Warfarin monitoring requires that all residents receiving Warfarin therapy be monitored for efficacy through observation and PT/INR testing. However, the facility did not follow this policy when the resident was placed on Bactrim. There was no indication that the facility informed the physician or the anticoagulation clinic about the resident's Coumadin therapy when Bactrim was prescribed. Consequently, the resident's INR was not monitored during the course of Bactrim treatment, leading to a critically high INR level. Interviews with the Director of Nursing revealed that the facility should have contacted the anticoagulation clinic and checked the INR within 1-3 days after starting the antibiotic. However, this process was not followed, resulting in the resident's increased risk for bleeding due to the high INR. The lack of communication and monitoring contributed to the deficiency in ensuring the resident's drug regimen was free from unnecessary drugs and adverse consequences.
Deficiencies in Pressure Injury Prevention and Treatment for Resident with Complex Medical History
Penalty
Summary
The facility failed to provide appropriate care to prevent and treat pressure injuries for resident R12, leading to the development of an infected stage 4 pressure injury. Despite R12's complex medical history, including nonverbal vascular dementia, severe Peripheral Arterial Disease, and other conditions, the facility did not consistently follow professional standards of practice in preventing and treating pressure injuries. Observations revealed instances where R12 was not repositioned regularly, had poor hand hygiene during wound care, and did not have his heels offloaded as ordered, all contributing to the development and worsening of the pressure injury. Furthermore, staff were not adequately addressing R12's pain management needs during wound care, as evidenced by R12 exhibiting signs of pain during the procedures. The facility also lacked proper documentation and communication with R12's Medical Doctor regarding changes in the wound status, such as the presence of slough and foul odor. Inconsistencies in wound assessments and inadequate reporting of important details, like the characteristics of the wound bed and drainage, further highlight the deficiencies in care provided to R12. The facility's failure to adhere to its own policies and procedures related to pressure injury prevention and treatment, as well as the lack of timely and appropriate interventions, resulted in the escalation of R12's pressure injury to an infected stage 4 ulcer. The deficiencies in care observed by surveyors, including inadequate pain management, poor wound care practices, lack of repositioning, and insufficient communication with the medical team, all contributed to the immediate jeopardy situation identified for resident R12.
Failure to Provide Daily Diabetic Foot Checks
Penalty
Summary
The facility did not ensure that four sampled residents received treatment and care in accordance with professional standards of practice for foot care. Specifically, the facility failed to provide daily diabetic foot checks as required by current standards of practice. The facility's policy on foot care did not reflect these standards, and there were no physician orders or comprehensive care plans indicating the need for daily diabetic foot checks for the residents involved. Interviews with nursing staff confirmed that foot checks were performed weekly or bi-monthly, rather than daily as required. Resident 1, who has Type 2 Diabetes Mellitus with diabetic neuropathy, did not have daily foot checks documented in their Medication/Treatment Administration Record (MAR/TAR) or physician orders. Similarly, Resident 12, with multiple diagnoses including severe Peripheral Arterial Disease and Diabetes Mellitus Type 2, also lacked daily foot checks in their care plan and physician orders. Resident 13, with Type 2 Diabetes Mellitus and a history of pressure ulcers, and Resident 35, also with Type 2 Diabetes Mellitus, were found to have similar deficiencies in their care plans and physician orders. Interviews with the Director of Nursing (DON) and Registered Nurses (RNs) revealed a lack of awareness and adherence to the current standards of practice for daily diabetic foot checks. The DON indicated that Certified Nursing Assistants (CNAs) regularly checked feet, but nurses only performed checks weekly or bi-monthly. This discrepancy between the facility's practices and the required standards of care led to the identified deficiencies in foot care for the diabetic residents.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food at an appetizing temperature, affecting four residents. Observations and interviews revealed that hot food was not always served hot and cold food was not served cold. Specifically, a test tray with French toast sticks, bacon, yogurt, and crushed strawberries showed that the French toast sticks were at 102.3 F and hard, while the crushed strawberries were at 60 F, both failing to meet the facility's policy requirements. Residents R3, R32, R36, and R20 all reported that their breakfast items, such as French toast sticks and crushed strawberries, were not served at the appropriate temperatures. The Dietary Manager acknowledged the issue, stating that hot foods should be served hot and cold foods should be served cold. The manager also mentioned plans to improve meal temperatures by serving meals in kitchenette areas. Despite these plans, the deficiency was evident as residents consistently reported receiving meals at incorrect temperatures, and the test tray confirmed these concerns. The facility's failure to adhere to its food temperature policy resulted in the deficiency noted by the surveyors.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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