Serenity Spring Senior Living At Scandia Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Sister Bay, Wisconsin.
- Location
- 10560 Applewood Rd, Sister Bay, Wisconsin 54234
- CMS Provider Number
- 525494
- Inspections on file
- 23
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Serenity Spring Senior Living At Scandia Village during CMS and state inspections, most recent first.
A resident with existing sacral and left heel pressure injuries did not receive consistent pressure ulcer care as ordered and recommended by a wound clinic. The sacral wound progressed from stage 2 to stage 3 with documented worsening, yet no alternating air mattress was obtained despite specific instructions to do so if the wound progressed. Treatment records showed multiple missed wound treatments, repositioning, and heel-floating opportunities, and surveyors observed the resident on a regular mattress without heel boots, with heels resting on the mattress and footboard, and a left heel dressing that had not been changed daily as ordered. The resident reported generally accepting care when offered, while nursing staff and the WRN confirmed that required dressing changes, heel offloading, and review of the wound clinic recommendations had not been consistently carried out.
The facility failed to ensure that ordered consistent carbohydrate (CCHO) diets were accurately implemented and that menu specifications were followed. A resident with type 2 DM was admitted with hospital orders for a 60 g carb-controlled diet, but the facility record reflected a 90 g CCHO order, and key dietary staff were unsure how many grams of carbohydrates the CCHO menu actually provided. Multiple residents with CCHO or CCHO/NAS diet orders, some cognitively intact and others cognitively impaired, reported or demonstrated that they did not consistently receive meals aligned with a CCHO diet and sometimes received large portions of high-carb foods such as potatoes, bread, and full dessert portions. Observation of a lunch meal showed that residents on CCHO diets received full slices of Boston cream pie instead of the half slice specified on the CCHO menu, confirming that prescribed diet orders and menu requirements were not consistently followed.
The facility failed to notify physicians when three residents’ blood glucose levels exceeded ordered parameters, contrary to its diabetes management and physician notification policies. One resident with severe cognitive impairment and diabetes had multiple blood sugar readings significantly above the ordered threshold without documented physician contact. Another resident with diabetes and intact cognition had blood sugars above the ordered reporting level on more than one occasion, and a third resident with multiple comorbidities, including diabetes and cirrhosis, also had a blood sugar reading above the notification parameter, again with no evidence of physician notification. The wound RN and DON confirmed the orders were current and that staff were expected to notify physicians for out-of-range readings, but no such notifications were documented.
Surveyors identified multiple deficiencies in food storage and kitchen sanitation, including uncovered and unclean equipment, lack of a cleaning schedule, uncovered food items, and improper storage of food boxes on the freezer floor. Staff confirmed these lapses were due to staffing transitions and incomplete cleaning routines, potentially affecting all residents.
The facility did not ensure that required background checks and documentation, including BID forms, DOJ reports, and IBIS reports, were completed for several staff members before they began working. Some staff worked multiple shifts before background checks were finalized, and others lacked updated or complete background check documentation, contrary to facility policy and state law.
Three residents or their legal representatives were not fully informed in advance of the risks and benefits of prescribed psychotropic medications, as required by facility policy. In each case, written consent forms were incomplete, missing, or not properly signed and dated, and essential information about the medications, alternative treatments, and consequences of refusal was not documented. Staff interviews confirmed that the required consent process was not followed.
A resident who was cognitively intact reported missing several labeled articles of clothing to multiple staff members, but no grievance forms were completed and the issue was not documented or investigated according to facility policy. Staff interviews confirmed awareness of the missing items, but appropriate grievance procedures were not followed.
A resident with severe cognitive impairment and anxiety was prescribed lorazepam 0.5 mg PRN for anxiety, irritability, and anger. The PRN order remained active and was not discontinued or reviewed after 14 days, contrary to facility policy, resulting in the medication being administered multiple times over several months without proper monitoring or physician review.
A resident who was transferred to the ED after a fall did not receive the required written notice of transfer, including appeal rights, Ombudsman contact information, and details about the bed-hold policy. Documentation was incomplete, and facility leadership could not confirm that the necessary information was provided at the time of transfer.
A resident with new diagnoses of depression and mood disorder, and a new prescription for an antidepressant, did not have their PASRR Level I Screen updated or a Level II Screen initiated as required. The facility's failure to update the screening was confirmed by the NHA, who indicated it was the Social Worker's responsibility.
A resident with dementia and Alzheimer's disease suffered a fall resulting in a wrist fracture, but the care plan was not updated to reflect the fall or include fall prevention interventions. Staff and management confirmed the care plan update was missed, and required protocols for revising care plans after significant changes in condition were not followed.
A resident with severe cognitive impairment returned from the hospital with instructions to apply Neosporin or bacitracin to a head laceration repaired with staples. The facility did not implement this wound care order until two days after the resident's return, as the discharge instructions were not reviewed or acted upon promptly by staff.
Surveyors found that pharmaceutical services were deficient when two residents had medications at their bedside without completed self-administration assessments, and an LPN administered a pill after picking it up with a bare hand, contrary to facility policy. Staff were unaware of the origin of some medications, and required assessments and documentation were missing at the time of the survey.
Two residents with cognitive impairment and complex medical histories did not have required monthly medication regimen reviews documented for several months. The DON confirmed that the missing reviews and pharmacist recommendations could not be located, despite the facility's process for monthly pharmacist review and follow-up.
The facility failed to thoroughly investigate potential neglect for two residents, leading to deficiencies in care. One resident experienced an unwitnessed fall and was later found deceased, with incomplete documentation and interviews. Another resident, with a clavicle fracture, had an insufficient investigation into the cause of the injury. The facility lacked a policy for abuse and neglect investigations, contributing to these deficiencies.
The facility failed to conduct thorough neurological checks for two residents following falls, as per their policy. One resident with multiple health conditions had inconsistent vital signs recorded after an unwitnessed fall, while another resident with moderate cognitive impairment had only half of the required neuro checks completed, with some vital signs reused from previous checks. The DON and NHA confirmed these deficiencies.
A resident with moderate cognitive impairment and a history of falls was observed without a required tab alarm while in a wheelchair. The care plan included this intervention to alert staff to the resident's movement, but it was not consistently implemented, as confirmed by staff and the Nursing Home Administrator.
The facility failed to store and prepare food in a sanitary manner, with multiple instances of open, unlabeled, and undated food items observed. Staff did not consistently wear hair or beard restraints, and the kitchen and food service areas were found to be unclean. The Dietary Director acknowledged the issues and indicated plans to address them.
The facility failed to establish and maintain infection control and water management programs, did not implement enhanced barrier precautions for residents with specific conditions, and staff did not perform appropriate hand hygiene during medication administration. Surveillance logs were incomplete, and the facility did not provide a Legionella Water Management Program when requested.
The facility failed to ensure the designated Infection Preventionist (IP) completed the required training and was employed at least part-time onsite. The IP worked remotely, and the certificate of completion for the training was incomplete, potentially affecting all 27 residents.
The facility failed to review and revise comprehensive care plans in a timely manner for six residents, with care plans being overdue by eight to sixteen days. This was due to turnover in the nursing department, transition of DON duties, and the use of remote staff.
The facility failed to obtain and document weekly weights for four residents as ordered by the physician. The issue was due to a broken scale in the dementia care unit, and despite efforts to resolve the problem, the facility did not comply with the physician's orders.
The facility failed to ensure that two residents or their representatives were informed and consented to the risks and benefits of their prescribed medications. The medical records for both residents lacked current consents, with the most recent consents dating back to 2022. The issue was attributed to turnover in Social Services and a part-time Social Services Director who worked remotely.
The facility failed to provide two residents with transfer notices and did not notify the Ombudsman when the residents were transferred to the hospital. Staff were unaware of the transfer policy, and the Nursing Home Administrator confirmed the oversight.
The facility failed to provide two residents with written information regarding the bed-hold policy upon their transfer to a hospital. One resident with moderately impaired cognition and another with intact cognition were not given the required documentation, as confirmed by the Nursing Home Administrator and an LPN.
The facility failed to accurately code MDS 3.0 assessments for two residents, omitting required BIMS scores and cognitive assessments. The issue was linked to staffing changes, including the retirement of a Social Worker and the part-time status of another, who were responsible for conducting the BIMS assessments.
The facility failed to complete a Level I PASRR Screen prior to admission for a resident with diagnoses including COPD, anxiety, and PTSD. The resident's medical record lacked the required PASRR Screen, and staff confirmed it should have been completed.
The facility failed to develop a baseline care plan within 48 hours of admission for a resident with multiple diagnoses, including mild neurocognitive disorder and chronic heart failure. Interviews with staff confirmed that the plan of care should be developed immediately upon admission and ideally completed within 48 hours, but this was not done in this case.
The facility failed to develop or implement an individualized comprehensive care plan for a resident requiring assistance with ADLs, specifically toileting and incontinence care. The resident often woke up in a wet bed, and the care plan did not include necessary interventions, leading to dissatisfaction from both the resident and their POAHC.
A resident with multiple diagnoses, including Alzheimer's and dementia, did not receive consistent assistance with toileting and incontinence care. The resident often woke up in a wet bed and was left in a chair all day because the bed was stripped and unmade. Staff interviews revealed a lack of understanding and inconsistent care for the resident's needs.
A resident with severe dementia and edema did not receive adequate care and treatment for edema. The care plan lacked interventions to treat, monitor, or provide relief for edema, and the physician was not updated on the effectiveness of a short-term medication order. Despite the presence of bilateral lower extremity edema, there was no current order for diuretic medication or other interventions such as compression stockings or repositioning.
The facility failed to ensure a safe environment for two residents reviewed for falls. One resident experienced two unwitnessed falls that were not thoroughly investigated, and the care plan was not updated. Another resident fell without wearing appropriate footwear, and the care plan was not updated following the fall. Staff members were unaware of the fall interventions in place, and the facility's protocols were not followed.
The facility failed to monitor a resident on long-term anticoagulant therapy for signs and symptoms of bleeding and bruising. The resident's plan of care did not include necessary interventions, a deficiency confirmed by the DON.
The facility failed to monitor adverse effects of psychotropic medications for three residents. One resident did not have a GDR attempted or documented contraindication, while two others lacked monitoring for adverse effects and AIMS assessments. The necessary documentation and monitoring were only completed after surveyor intervention.
The facility did not ensure the required members of the QAPI committee met at least quarterly, impacting all 27 residents. Three of four required quarterly QAPI meetings over the past year did not have the MD, NHA, DON, and/or IP in attendance as required.
Failure to Follow Wound Clinic Orders and Provide Consistent Pressure Injury Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure injury care and treatment to promote healing and prevent worsening of existing pressure injuries for one cognitively intact resident with multiple comorbidities, including CHF and type 2 diabetes. Upon admission, the resident had a stage 2 sacral pressure injury (identified by the facility as coccyx) and a deep tissue injury (DTI) on the left heel. Admission wound clinic documentation emphasized that offloading was of utmost importance, directing that the resident be turned side-to-side every two hours, not lie directly on the sacrum, and that an alternating pressure mattress be initiated as soon as possible if the sacral wound progressed. The same documentation instructed that the left heel DTI be kept covered with a protective border dressing and that heel boots be used at all times to float the heels off the mattress. Subsequent wound assessments documented that the coccyx/sacral wound worsened over several weeks, progressing from a stage 2 to a stage 3 pressure injury with increasing size and development of slough and eschar, yet the medical record contained no indication that an alternating air mattress was ordered despite the wound clinic’s recommendation tied to wound progression. The left heel DTI also increased in size and changed in character, with notes indicating the wound had worsened or was larger and darker, and orders were in place for daily dressing changes and continuous use of heel boots or heel-floating. Treatment Administration Records for January and February showed multiple missed wound treatments for both the coccyx and left heel, as well as missed repositioning and heel-floating opportunities, despite the care plan interventions to reposition the resident at least every two hours and keep heels floated or in heel boots at all times. During surveyor observations on multiple occasions, the resident was found in bed on a regular pressure-relieving mattress rather than an alternating air mattress, without heel boots in place, and with both heels in contact with the mattress and footboard. The left heel dressing was dated six days prior, although orders required daily dressing changes. The resident reported generally accepting wound care and heel boots when offered and did not indicate frequent refusals. Nursing staff acknowledged that the heel dressing had not been changed on the observed shift because it was not assigned, and the Wound RN confirmed that the heel dressing was overdue for change and that the resident’s heels should have been floated with heel boots or pillows. The Wound RN also stated that the wound clinic note with the alternating mattress recommendation had not been reviewed prior to survey, and there was no documentation that an alternating air mattress had been obtained during the period when the wound was documented as worsening.
Failure to Follow Ordered Consistent Carbohydrate Diets and Menu Specifications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered consistent carbohydrate (CCHO) diets were accurately implemented and that menus met residents’ prescribed nutritional needs. The facility’s Controlled Carbohydrates policy states that carbohydrates should be balanced consistently at each meal, providing 70–80 grams of carbohydrates, and that these diets can be used for diabetic residents with glucose control concerns. However, for one resident with type 2 diabetes, hospital discharge orders specified a carb-controlled diet of 60 grams of carbohydrates per meal, while the facility’s medical record contained an order for a CCHO, no added salt diet providing 90 grams of carbohydrates per meal. The Dietary Manager was unaware that this resident’s diet order specified 90 grams of carbohydrates and did not know how many grams of carbohydrates were provided on the facility’s CCHO menu. The Registered Dietitian stated that a carb-controlled diet is usually 55–70 grams of carbohydrates per meal, that higher carbohydrate orders should be followed by providing additional carbohydrates, and that specific carbohydrate orders should be communicated to the Dining Director so meal tickets can be adjusted, but was also unsure how many carbohydrates per meal the facility’s menu provided. Additional residents with diagnoses including type 2 diabetes and stroke had active orders for CCHO or CCHO no added salt diets, yet reported or demonstrated that they did not consistently receive meals aligned with those diets. One cognitively intact resident with type 2 diabetes reported preferring to follow a CCHO diet but stated they did not always receive it and were served a lot of potatoes and bread, which they would prefer to avoid. Another cognitively intact resident with type 2 diabetes reported preferring to follow a CCHO diet but stated they did not always receive it and therefore chose to eat smaller portions or avoid items they felt did not fit a CCHO diet. Several other residents with CCHO or CCHO no added salt diet orders had varying levels of cognitive impairment, including severe impairment, and were dependent on staff and the facility’s systems to ensure their prescribed diets were followed. During an observation of lunch service, the surveyor reviewed the lunch menu for residents on a CCHO diet, which specified 3 oz baked ham, 4 oz scalloped potatoes, 4 oz buttered green beans, 1 dinner roll, and a half slice of Boston cream pie. When observing the trays prepared in the kitchen, the surveyor noted that each tray, including those for residents on CCHO diets, contained a slice of pie that appeared to be the same size, rather than a half slice as indicated on the menu. The Dietary Manager acknowledged noticing that residents on CCHO diets did not receive a half piece of pie and confirmed that they should have received a half slice according to the menu. These observations, combined with staff interviews and record review, showed that residents with CCHO diet orders did not consistently receive meals that matched their prescribed diets or the facility’s stated carbohydrate-controlled menu.
Failure to Notify Physicians of Critically Elevated Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians when residents’ blood glucose levels exceeded ordered parameters, despite existing policies requiring such notification. The facility’s Diabetes Policy and Guidelines for Notifying Physicians of Clinical Problems state that physicians will set parameters for blood sugar monitoring and that significant fluctuations in blood sugar require physician notification, with these parameters to be incorporated into the MAR and care plan. For one resident with type 2 diabetes, stroke, anxiety, and severe cognitive impairment, the care plan included monitoring for signs and symptoms of hyperglycemia and a physician order to call if blood sugar was over 450 mg/dL. Over the course of a month, this resident’s blood sugars were repeatedly recorded between 471 mg/dL and 598 mg/dL on multiple occasions, yet the medical record contained no documentation that the physician was notified. Another resident with a femur fracture, diabetes mellitus, and intact cognition had a care plan goal of no signs or symptoms of hyperglycemia and an order to call the physician if blood sugar exceeded 350 mg/dL. This resident’s blood sugars reached 481 mg/dL and 352 mg/dL on separate occasions, with no record of physician notification. A third resident with metabolic encephalopathy, cirrhosis of the liver, history of stroke, type 2 diabetes, and moderate cognitive impairment had an order to notify the physician if blood sugar was over 450 mg/dL; this resident’s blood sugar reached 456 mg/dL, again without documentation of physician notification. During interviews, the wound RN and the DON confirmed that the blood sugar parameters were current, that staff were expected to notify physicians for out-of-parameter readings, and that they could not find documentation that physicians had been notified for these elevated blood sugars.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Surveyors found that the facility failed to store and prepare food in a safe and sanitary manner, as required by professional standards and the Wisconsin Food Code. During observations, the deep fryer was found uncovered, with food debris present both in the oil and along the sides, and there was no established cleaning schedule for the fryer. Staff confirmed that the fryer oil was only changed when visibly dirty and that no written cleaning schedule was in place due to a transition between Dietary Managers. Additionally, a container of butter was left uncovered in the prep area, exposing it to potential contaminants. Equipment in the kitchen, including the stove top, hood vent, and microwave, was observed to be unclean, with dried food debris and greasy substances present. Staff acknowledged these conditions and indicated that cleaning had not been completed due to staffing issues and food preparation needs. Further, surveyors observed fifteen boxes of food stored directly on the freezer floor, contrary to food storage requirements that mandate food be kept at least six inches above the floor. Staff explained that the boxes had not been put away because the responsible cook had quit and other staff had not yet addressed the delivery. These findings indicate multiple lapses in food storage, preparation, and equipment cleanliness, with the potential to affect all 40 residents in the facility.
Failure to Complete Required Staff Background Checks Prior to Employment
Penalty
Summary
The facility failed to implement its abuse prevention policy by not ensuring that required background checks and documentation were completed for five of eight employees reviewed. Specifically, one CNA began working and completed multiple shifts before filling out a Background Information Disclosure (BID) form and before the Department of Justice (DOJ) background check was obtained. Additionally, this CNA did not have an Integrated Background Information System (IBIS) report on file. Two other staff members, a CNA and a Dietary Aide, also lacked IBIS reports in their background check files. Another CNA had not had a background check completed within the last four years, as required by state law. For one RN, the DOJ and IBIS reports were completed before the BID form was signed, which is not in accordance with policy or legal requirements. The facility's Employee Screening policy and Wisconsin State Statute 50.065 require that all caregivers have completed background checks, including BID forms, DOJ reports, and IBIS reports, prior to employment and at least every four years thereafter. During interviews, the Nursing Home Administrator confirmed that several required background checks and forms were missing or completed out of order, and that some staff began working before these checks were finalized. The administrator also acknowledged a lack of awareness regarding the missing documentation and confirmed the sequence of events that led to the deficiency.
Failure to Obtain Complete Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medications, as required by facility policy. For one resident with severe cognitive impairment and an activated Power of Attorney for Healthcare (POAHC), multiple psychotropic medications were prescribed, including lorazepam, duloxetine, trazodone, and quetiapine. The medical record showed that only verbal consent was obtained, with incomplete and undated written consent forms lacking initials and signatures from the POAHC, and no documentation of attempts to obtain proper written consent. Another resident with moderate cognitive impairment and an activated POAHC was prescribed venlafaxine and bupropion. The consent forms for these medications were incomplete, missing essential information such as the method of administration, reasons for the medication, alternative treatments, probable consequences of not receiving the medication, and staff signatures. For a third resident with intact cognition, the consent form for citalopram was also incomplete, lacking information on alternative treatments and the consequences of not receiving the medication. Interviews with facility staff confirmed that the protocol requires the social worker to obtain written consent from the resident or POA, with a written signature to be obtained within 10 days if verbal consent is initially given. However, the documentation reviewed did not meet these requirements, as written consents were either missing, incomplete, or not properly signed and dated, leading to the deficiency.
Failure to Investigate and Document Resident Grievance Regarding Missing Personal Items
Penalty
Summary
A resident, who was cognitively intact and able to make their own healthcare decisions, reported to several staff members that seven articles of clothing were missing, including labeled items such as t-shirts, an over-shirt, sweatpants, and a sweatshirt. Despite informing housekeeping and laundry staff, as well as mentioning that some items had been missing since the previous year, no grievance forms were filled out regarding the missing items. The facility's grievance file did not contain any documentation related to these missing articles, and the facility's grievance policy was not provided during the survey. Interviews with staff revealed that the housekeeper, who also worked in laundry, was aware of the missing clothing and had previously addressed similar issues with the former social worker. However, the housekeeper did not notify the Nursing Home Administrator or the Director of Nursing, nor did they complete a grievance form, hoping instead that the items would be found. The Nursing Home Administrator confirmed that staff are expected to fill out grievance forms for missing items, but this procedure was not followed in this case.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
A deficiency occurred when the facility failed to monitor and appropriately discontinue a psychotropic medication, lorazepam, prescribed as needed (PRN) for a resident with Alzheimer's disease, dementia with behavioral disturbance, and anxiety disorder. The resident, who had severely impaired cognition and an activated Power of Attorney, had an order for lorazepam 0.5 mg PRN every 6 hours for anxiety, irritability, and anger, starting on 2/25/25. According to the facility's policy, PRN orders for psychotropic medications are limited to 14 days unless the prescriber documents a rationale for extending the order. However, the order for lorazepam remained active without an end date and was not reviewed or discontinued after 14 days as required. Review of the resident's Medication Administration Record showed that lorazepam was administered multiple times over several months, indicating ongoing use beyond the 14-day limit. The Director of Nursing confirmed that the original PRN order was still active and had not been discontinued or reviewed as per policy. The oversight was identified during a survey, and the DON acknowledged that the PRN lorazepam order should have been discontinued after 14 days, as stipulated by facility policy.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a resident who was transferred to the Emergency Department with the required written notice of transfer, including the reason for transfer, location of transfer, appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman. Additionally, the resident did not receive written information regarding the facility's bed-hold policy, the reserve bed payment policy, or the right to return to the facility. The facility's policy requires that all residents receive this information in writing at the time of transfer or within 24 hours if the transfer is an emergency. Record review showed that the resident, who was cognitively intact according to a recent MDS assessment, was transferred following a fall with head injury. The documentation provided was incomplete, lacking appeals information, daily rate, and Ombudsman contact details. Interviews with facility leadership revealed uncertainty about whether the required information was provided at the time of transfer, and the resident confirmed not receiving the notice until days after the transfer. The facility was unable to produce documentation showing that the required notifications were given as mandated by policy.
Failure to Update PASRR Screening After New Mental Health Diagnoses and Medication
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR) Level I Screen was updated and a Level II Screen was initiated when a resident developed new mental health diagnoses and was prescribed new psychotropic medication. The resident was admitted with diagnoses including fracture, anemia, hypertension, depression, and mood disorder, and had a BIMS score indicating intact cognition. The initial PASRR Level I Screen did not indicate the need for a Level II evaluation. However, subsequent medical records showed the resident was diagnosed with a mood disorder and depression and was prescribed citalopram, an antidepressant. Despite these changes, the facility did not update the PASRR Level I Screen or submit for a Level II reevaluation. The Nursing Home Administrator confirmed that the required PASRR updates were not completed following the new diagnoses and medication orders, and stated that it was the Social Worker's responsibility to complete these screens.
Failure to Update Care Plan After Resident Fall with Injury
Penalty
Summary
A resident with diagnoses including dementia, Alzheimer's disease, and diabetes experienced a fall resulting in a left wrist fracture. Despite the fall and subsequent injury, the resident's care plan was not updated to reflect the incident or to include interventions aimed at preventing future falls. The facility's policies require that care plans be revised following significant changes in a resident's condition, such as a fall with injury, and that interventions be implemented to address new risks. However, the care plan for this resident, initiated prior to the fall, did not document the fall or any fall prevention strategies. Staff interviews and record reviews confirmed that the omission occurred, with nursing staff and management acknowledging that the care plan update was missed. The facility's own protocols specify that care plans should be reviewed and revised as residents' conditions change, but this process was not followed after the resident's fall. Additionally, staff education on updating care plans after such incidents had not been completed at the time of the survey.
Delay in Implementing Hospital Discharge Wound Care Orders
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including adult failure to thrive and chronic low back pain, experienced an unwitnessed fall resulting in a head laceration. The resident was transferred to the emergency room, where the laceration was repaired with staples. Upon discharge, the hospital provided instructions to wash the wound and apply Neosporin or bacitracin ointment. However, upon the resident's return to the facility, these wound care instructions were not implemented immediately. The medical record and staff interviews confirmed that the order to apply Neosporin or bacitracin was not obtained or started until two days after the resident's return, following a fax to the provider for clarification. There was no documentation that the ER discharge orders were reviewed upon the resident's return, and the Director of Nursing was unable to explain why the wound care was not initiated as directed. As a result, the resident did not receive the prescribed wound care treatment according to the hospital's discharge instructions.
Deficiencies in Medication Administration and Self-Administration Assessments
Penalty
Summary
Surveyors identified deficiencies in the facility's pharmaceutical services related to medication administration and self-administration assessments. For one resident with congestive heart failure, renal insufficiency, diabetes, and malnutrition, unlabeled and undated lubricating eye drops were found at the bedside, along with other medications not provided by the facility pharmacy. There were no physician orders or self-administration assessments for these medications, and staff were unaware of their origin or whether the resident was permitted to self-administer them. Another resident with acute panmyelosis with myelofibrosis, osteopathic conditions, and dry eyes was observed self-administering Refresh Tears eye drops, which were labeled with the resident's name and kept at the bedside. The resident's medical record included a physician order for unsupervised self-administration of the eye drops, but there was no documented self-administration assessment to support this practice at the time of the survey. Additionally, a bottle of multivitamins was found at the bedside without proper assessment. During medication administration for a third resident, an LPN dropped a pill on the medication cart, picked it up with a bare hand, and administered it to the resident, contrary to the facility's policy prohibiting staff from touching medications with their hands. The LPN acknowledged the error, and the DON confirmed that the pill should have been disposed of and not administered. These findings demonstrate failures in following established policies for medication safety and proper assessment for self-administration.
Failure to Complete and Document Monthly Medication Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed and documented monthly medication regimen reviews (MMRs) for two of five sampled residents. For one resident with hypertension, depression, and a history of stroke, the medical record lacked MMRs for three separate months. This resident had moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC). For another resident with Alzheimer's disease, dementia with behavioral disturbance, anxiety, insomnia, and depression, the MMR for one month was missing. This resident had severe cognitive impairment and was also under an activated POAHC. Surveyors reviewed the medical records for both residents and confirmed the absence of the required MMR documentation for the specified months. The Director of Nursing (DON) verified that the facility could not locate the missing MMRs or any pharmacist recommendations for these residents. The DON also confirmed that the facility's process involves the pharmacist emailing all recommendations to the DON for physician follow-up, but the documentation for the months in question was not available.
Inadequate Investigation of Potential Neglect Incidents
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential neglect for two residents, R2 and R1, leading to deficiencies in care. R2, who had intact cognition and multiple medical conditions, experienced an unwitnessed fall and was found deceased hours later. The investigation into R2's fall was incomplete, as it did not include interviews with CNAs or documentation of when R2 was last seen alive. Additionally, there was a lack of CNA documentation for the overnight shift, and the neuro checks were not consistently documented between the time of the fall and when R2 was found deceased. R1, who had moderate cognitive impairment and a clavicle fracture, was sent to the hospital after complaining of new pain. The facility's investigation into R1's fall was insufficient, as it only included interviews with R1 and one nursing staff member present at the time of the fall. The investigation did not explore other potential causes for the fracture or include interviews with other staff who worked during the period between the fall and the change in R1's condition. The facility was unable to provide a policy related to abuse and neglect investigations, which further contributed to the deficiencies. The lack of thorough investigations and documentation for both residents highlights significant gaps in the facility's response to potential neglect and abuse incidents.
Failure to Complete Neurological Checks as per Policy
Penalty
Summary
The facility failed to ensure thorough neurological checks were completed according to their policy for two residents following falls. Resident R2, who had a history of cerebral infarction, familial dysautonomia, congestive heart failure, sick sinus syndrome, and chronic kidney disease, experienced an unwitnessed fall on 8/24/24. The facility's policy required neuro checks every 30 minutes for two hours, then every eight hours for three days. However, the neuro check forms for R2 showed inconsistencies, with some vital signs being reused from previous checks instead of obtaining new ones as required. The Director of Nursing confirmed that not all vital signs were completed as per the policy. Similarly, Resident R1, who had a clavicle fracture and moderate cognitive impairment, fell and hit their head on 8/17/24. The facility's policy required neuro checks every 30 minutes for two hours, then every eight hours for three days. However, only six out of the required twelve neuro checks were completed, and some vital signs were reused from previous checks. The Nursing Home Administrator acknowledged that the neuro checks were not completed per the facility's policy and that new vital signs should have been taken for each check.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate assistive devices and interventions were in place to prevent falls for a resident, identified as R1, who was part of a sample of three residents. R1's care plan included an intervention for a tab alarm to alert staff to the resident's movement and assist in monitoring. However, this intervention was not consistently implemented. On the day of the survey, R1 was observed in their room sitting in a wheelchair without the tab alarm connected to their clothing. A Certified Nursing Assistant (CNA) later connected the alarm after being prompted by the surveyor, indicating that the alarm should have been in place earlier. R1 was admitted to the facility with diagnoses including a clavicle fracture and muscle weakness, and had a moderate cognitive impairment as indicated by a BIMS score of 12 out of 15. The resident's care plan, created several months prior, noted gait and balance problems and poor safety awareness, necessitating the use of a tab alarm. Despite this, the alarm was not in place during a critical period, as confirmed by the Nursing Home Administrator, who acknowledged that the alarm should have been connected while R1 was in the wheelchair in their room.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a sanitary manner, which had the potential to affect all 27 residents residing in the facility. During an initial tour of the kitchen, the surveyor observed multiple instances of open, unlabeled, and undated food items in various storage areas, including the dry storage, walk-in cooler, reach-in cooler, and freezer. The Dietary Director (DD) confirmed that the facility follows the FDA Food Code, which requires ready-to-eat, time/temperature control for safety food to be clearly marked with open or use-by dates. However, numerous items were found without proper labeling, making it difficult to appropriately use food in a FIFO (first in/first out) rotation and ensure food safety. The DD acknowledged the oversight and indicated plans to schedule an in-service to ensure all staff followed the policy and dispose of the unlabeled and undated items. Additionally, the facility failed to ensure that staff consistently wore hair or beard restraints throughout the kitchen. The surveyor observed the Dietary Director's hair net not fully covering their hair, a cook preparing and serving food without a hair or beard net, and a maintenance man entering the kitchen without proper hair or beard restraints. The DD verified that all staff should wear hair nets and beard nets (if needed) in the kitchen that fully cover any and all hair, and acknowledged the lapses in compliance. The cleanliness of the kitchen and food service areas was also found to be substandard. The surveyor noted dark-colored debris inside the ice machine, grease and debris around the fryer, uncovered large cooking pots with water, and unclean shelves and floors in the kitchen and dishwashing areas. The walk-in cooler also contained spills on the floor. The DD admitted that the areas were unacceptable and needed to be addressed immediately. The DD also mentioned that cleaning duties were not assigned, although concerns had been brought to the Quality Assurance and Performance Improvement (QAPI) meeting and a new cleaning list had been made, but not yet implemented or communicated to the kitchen staff.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility did not establish and maintain infection control and water management programs designed to help prevent the development and transmission of disease and infection. The facility failed to implement enhanced barrier precautions for four residents with conditions such as indwelling catheters, wound care, and intravenous antibiotics. Additionally, staff did not perform appropriate hand hygiene during medication administration for five residents, which had the potential to affect all 27 residents residing in the facility. The facility did not maintain surveillance logs to assist with the recognition of trends and patterns of infection to help prevent the spread of communicable disease. The facility also failed to monitor residents for signs and symptoms of infection. The infection surveillance data provided was incomplete and did not include information on several residents who had infections or were prescribed antibiotics. The facility's Infection Preventionist and Regional Consultant were unable to provide complete and accurate surveillance data during the survey. The facility did not have a water management program that identified areas in the water system where Legionella could grow and spread, and to reduce the risk of Legionnaires' disease. The facility's Legionella Water Management Program was requested multiple times by the surveyor but was not provided. Additionally, staff were not adequately trained on enhanced barrier precautions, as evidenced by their lack of knowledge and improper use of personal protective equipment during high-contact resident care activities.
Inadequate Infection Preventionist Presence and Training
Penalty
Summary
The facility did not ensure that the designated Infection Preventionist (IP) completed the required infection prevention and control training and was employed at least part-time in the facility. During the entrance conference, the Nursing Home Administrator (NHA) identified the Director of Nursing (DON) as the IP. However, upon further investigation, it was revealed that the DON was only an interim DON and not the IP. The facility's previous DON, who was also the IP, had left employment, and the current IP was working remotely without being present in the facility at least part-time as required by regulations. Additionally, the certificate of completion for the infection prevention and control training for the current IP was incomplete and did not cover all required modules or indicate the hours of training completed and successful completion of the program. The surveyor's interviews with the NHA, DON, Regional Consultant (RC), and the remote IP revealed inconsistencies and a lack of clarity regarding the designation of the IP. The remote IP had been overseeing the facility's infection prevention and control program since January 2024 but had not been physically present in the facility. The facility had an interim plan in place, but the required certification for the IP's training was not provided to the surveyor. This deficiency had the potential to affect all 27 residents residing in the facility, as the infection prevention and control program was not being adequately managed onsite by a qualified IP.
Failure to Review and Revise Comprehensive Care Plans Timely
Penalty
Summary
The facility did not ensure the comprehensive plan of care was reviewed and revised in a timely manner for six residents. The care plans for these residents were not reviewed prior to or on the due dates listed on the care plans. Specifically, the care plans for the residents were overdue by several days, ranging from eight to sixteen days past the due date. This deficiency was identified through staff interviews and record reviews conducted by the surveyor. The facility's policy and federal regulations require that comprehensive care plans be developed within seven days of the completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment. However, due to turnover in the nursing department, the transition of DON duties, and the use of remote staff, the facility failed to meet these requirements. Despite a past non-compliance plan being identified and reviewed, the care plans for the six residents remained overdue and incomplete.
Failure to Obtain Weekly Weights as Ordered
Penalty
Summary
The facility failed to ensure that weights were obtained per physician orders for four residents. Specifically, the medical records for these residents did not contain the required weekly weights as ordered by the physician. The residents involved had severe cognitive impairments and various medical conditions, including dementia, anxiety, and vitamin deficiencies. The deficiency was identified during a review of medical records and staff interviews, revealing that weights were only documented monthly instead of weekly as required by the physician's orders. The issue was traced back to a broken scale in the dementia care unit, which had been out of service since October 2023 due to a lightning strike. Staff were aware of the broken scale but faced challenges in transporting residents to another unit for weighing. Despite attempts to obtain a new scale and a plan to monitor weights, the facility did not comply with the physician's orders for weekly weights. Interviews with staff, including a Certified Nursing Assistant and a Regional Consultant, confirmed the ongoing problem and the facility's awareness of the issue. Emails and documentation provided by the facility showed efforts to resolve the scale issue, including communication with the previous owners responsible for payment and attempts to order new scales. However, these efforts were not completed in a timely manner, and the facility's Performance Improvement Plan, which included measures to ensure weights were obtained, was not fully implemented. The facility's failure to obtain and document weights as ordered by the physician resulted in non-compliance with regulatory requirements.
Failure to Obtain Current Medication Consents
Penalty
Summary
The facility did not ensure that two residents or their representatives were informed and consented to the risks and benefits of their prescribed medications. Resident 16 was prescribed multiple medications, including Seroquel, Lexapro, Depakote, Paxil, Buspar, and Namenda. However, the medical record did not contain current consents for these medications, with the most recent consents dating back to 2022 and earlier. The resident's power of attorney (POA) confirmed that they had not signed recent medication consents and were unaware of the current medications prescribed to the resident. Similarly, Resident 20 was prescribed Seroquel, Depakote, Paxil, Namenda, and Exelon, but the medical record also lacked current consents for these medications, with the most recent consents signed in 2022. The facility's Regional Consultant confirmed that the facility did not obtain and review medication consent forms within the required 15-month timeframe. The issue was attributed to turnover in Social Services and a part-time Social Services Director who worked remotely. Despite efforts to locate current signed informed consent forms, they were not provided to the surveyor.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility did not ensure that two residents, R12 and R22, received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, and appeal rights. Additionally, the facility failed to notify the Ombudsman of these transfers. R12, who had moderately impaired cognition, was transferred to the hospital due to redness and pain in the right leg but did not receive a written transfer notice, nor was the Ombudsman notified. Similarly, R22, who had intact cognition, was transferred to the hospital after sustaining a head laceration during an unwitnessed fall, but also did not receive a written transfer notice, and the Ombudsman was not notified. The facility's Transfer Agreement policy, effective since 8/1/17, mandates that a written transfer notice and Ombudsman notification should be provided whenever a resident is transferred to the hospital. However, staff interviews revealed that the Licensed Practical Nurse (LPN) was unaware of this policy, and the Nursing Home Administrator (NHA) confirmed the failure to provide the required notices. The surveyor's review of the medical records and subsequent requests for the transfer notices and Ombudsman notifications for both residents were not met, confirming the deficiency.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility did not ensure that two residents, R12 and R22, received written information regarding the duration of the facility's bed-hold policy, the reserve bed payment policy, and the right to return to the facility upon transfer to a hospital. R12, who had moderately impaired cognition, was transferred to the hospital on 6/3/23 due to redness and pain in the right leg but was not provided with a copy of the facility's bed-hold policy. This was confirmed by the Nursing Home Administrator (NHA) and a Licensed Practical Nurse (LPN) who were unaware of the policy. Similarly, R22, who had intact cognition, was transferred to the hospital on 11/17/23 after sustaining a laceration to the head during an unwitnessed fall. R22's medical record also did not indicate that a copy of the bed-hold policy was provided. The NHA confirmed that R22 was not given the facility's bed-hold policy at the time of transfer. Both instances highlight a failure to comply with the facility's own Bed-Holds and Returns policy, which mandates providing written information about bed-hold policies at least twice, including at the time of transfer.
Failure to Accurately Code MDS Assessments
Penalty
Summary
The facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for two residents, R4 and R21, out of 13 sampled residents. R4's MDS assessment dated 2/21/24 and 11/21/23 did not contain a Brief Interview for Mental Status (BIMS) score or indicate that R4's cognition was assessed. Similarly, R21's MDS assessment dated 3/28/24 and 12/28/23 also lacked a BIMS score or any indication that R21's cognition was assessed. Both residents had significant medical histories, with R4 diagnosed with chronic kidney disease, type two diabetes, and heart failure, and R21 diagnosed with Alzheimer's disease, dementia, cerebral infarction, and type two diabetes. The deficiency was attributed to the facility's failure to complete the BIMS assessments as required. The Regional Consultant (RC-C) and the Minimum Data Set Coordinator (MDSC-D) confirmed that the MDS assessments were supposed to include BIMS scores. The MDSC-D indicated that the BIMS assessments were not completed due to the retirement of a Social Worker and the part-time status of another Social Worker, who were responsible for conducting the in-person resident interview questions, including the BIMS assessment. Despite the facility's policy requiring timely and accurate MDS submissions, these assessments were not completed as expected.
Failure to Complete Level I PASRR Screen Prior to Admission
Penalty
Summary
The facility did not ensure a Level I Pre-Admission Screening and Resident Review (PASRR) Screen was completed prior to admission for one resident (R22). R22 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety, and post-traumatic stress disorder (PTSD). A review of R22's medical record revealed that the Minimum Data Set (MDS) assessment indicated intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. However, the medical record did not contain a Level I PASRR Screen. During interviews, both the Regional Consultant and the Nursing Home Administrator confirmed that a Level I PASRR Screen should have been completed for a resident with a diagnosis of anxiety.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility did not ensure a baseline care plan was developed or provided within 48 hours of admission for one resident. The resident, who was admitted with multiple diagnoses including mild neurocognitive disorder, urinary tract infection, type two diabetes with hyperglycemia, chronic heart failure, and chronic atrial fibrillation, did not have a baseline care plan created within the required timeframe. The resident's medical record contained an unspecified care plan created outside of the 48-hour requirement, and no other care plans were available at the time of the survey. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that the plan of care should be developed immediately upon admission and ideally completed within 48 hours. The plan of care should be resident-specific and include the resident's name, diagnoses, goals, and pertinent care information. The Regional Consultant also confirmed that the facility follows the care plan policy provided to the surveyor, which mandates the creation of a baseline care plan within 48 hours of admission.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop or implement an individualized comprehensive care plan for a resident (R21) who required assistance with activities of daily living (ADL), specifically toileting and incontinence care. Despite R21's medical record indicating a need for partial/moderate assistance with toileting hygiene and occasional incontinence, the care plan did not include any interventions related to these needs. Observations and interviews revealed that R21 often woke up in a wet bed, which was left unmade throughout the day, and the resident expressed dissatisfaction with the care provided. Additionally, R21's Power of Attorney for Healthcare (POAHC) confirmed that the facility did not address different approaches to support R21's needs and expressed dissatisfaction with the care provided. The facility's policy required that comprehensive care plans be developed within seven days of the completion of the comprehensive assessment and be reviewed and revised by the interdisciplinary team after each assessment. However, the facility did not adhere to this policy for R21. Interviews with the Nursing Home Administrator and the Regional Consultant confirmed that the care plan should be resident-specific and include the resident's diagnoses, goals, and pertinent care information, which was not done in this case.
Inconsistent Assistance with ADLs for Resident
Penalty
Summary
The facility did not provide consistent assistance with activities of daily living (ADLs) for a resident (R21) who required help with toileting and incontinence care. R21, who had diagnoses including Alzheimer's disease, dementia, stroke, type two diabetes, anxiety, UTI, and sepsis, was observed in a wet bed on multiple occasions. The resident's medical record indicated a need for partial/moderate assistance with toileting hygiene, but the plan of care did not include interventions for ADL self-care performance deficits. Interviews with R21 and their Power of Attorney for Healthcare (POAHC) revealed dissatisfaction with the care provided, noting that R21 often woke up in a wet bed and was left in a chair all day because the bed was stripped and unmade. The POAHC also mentioned that staff did not encourage or assist R21 to wear pads provided to help with nighttime incontinence. Staff interviews indicated a lack of consistent care and misunderstanding of R21's needs. Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) provided conflicting information about R21's level of independence and the frequency of checks. CNA-E and CNA-F stated that R21 was mostly independent and only occasionally incontinent, while LPN-G acknowledged that R21 needed help with bed changes and required reminders and cues. Despite these needs, the staff did not consistently check on R21 or provide the necessary assistance, leading to the resident frequently waking up in a wet bed and experiencing discomfort and neglect.
Failure to Provide Adequate Care and Treatment for Edema
Penalty
Summary
The facility did not ensure the provision of care and treatment in accordance with professional standards of practice for a resident with edema. The resident's care plan did not contain interventions to treat, monitor, or provide relief for edema. Additionally, the facility failed to update the resident's physician on the effectiveness of a short-term medication order for edema. The resident had a diagnosis of severe dementia with mood disturbance, amnesia, anxiety, and edema, and had severely impaired cognition as indicated by a BIMS score of 0 out of 15. Despite the presence of bilateral lower extremity edema, there was no current order for diuretic medication or other interventions such as compression stockings or repositioning to address the edema. The Director of Nursing (DON) confirmed that the resident did not have an order for a diuretic medication to treat edema and verified that the care plan did not contain interventions to evaluate or monitor for edema. The DON indicated that atenolol, a beta blocker medication, was ordered for hypertension but could assist with edema as well. However, the resident's medical record did not contain updates to the physician regarding the effectiveness of the previously prescribed Lasix, a diuretic medication, or any other interventions to assist with edema relief. The physician was not updated on the effectiveness of the Lasix, did not receive further communication about continuing the Lasix, and did not receive requests for additional interventions. The surveyor's review of the resident's medical record revealed that the resident was administered Lasix for five days, but there was no continuation of the Lasix order or an update to the care plan to monitor for edema. The physician saw the resident again and noted swelling in both lower extremities but did not provide a further plan at that time. An addendum to the assessment and plan indicated that nursing staff commented on the resident's increased swelling, and Lasix was prescribed again for five days. However, there was no continuation of the Lasix order or an update to the care plan to monitor for edema, leading to the deficiency in care and treatment for the resident's edema.
Failure to Implement Fall Interventions and Update Care Plans
Penalty
Summary
The facility did not ensure the environment remained as free of accident hazards as possible for two residents reviewed for falls. Resident 22 experienced two unwitnessed falls on 9/16/23 and 11/17/23. The falls were not thoroughly investigated to determine the root cause, and Resident 22's plan of care was not updated to prevent future falls. Observations revealed that Resident 22 was not wearing the appropriate footwear as per the care plan, and staff members were unaware of the fall interventions in place for Resident 22. The Director of Nursing (DON) confirmed that the falls were not investigated or discussed in follow-up meetings, and the care plan was not updated after the falls occurred. Resident 16 fell on 4/22/24, and the fall interventions contained in Resident 16's plan of care were not implemented at the time of the fall. The progress note indicated that Resident 16 was not wearing footwear during the fall. The care plan for Resident 16, which included ensuring the resident wore appropriate footwear, was not updated following the fall. Interviews with staff members revealed that they were not informed of Resident 16's fall or any new interventions that were implemented. The DON confirmed that a fall investigation, root cause analysis, and care plan update for Resident 16 did not occur because nursing staff did not follow the fall intervention that was already in place. The facility's Falls-Clinical Protocol and Goals and Objectives, Care Plans policy were not followed, leading to deficiencies in fall prevention and care plan updates for both residents. The lack of thorough investigation, root cause analysis, and communication among staff members contributed to the failure to implement appropriate fall interventions and update care plans to prevent future falls.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility did not ensure monitoring of a high-risk medication for one resident (R22) who was on long-term anticoagulant therapy. R22, who had intact cognition and was admitted with diagnoses including COPD, anxiety, muscle weakness, difficulty walking, and long-term anticoagulant use, had a physician order for Eliquis 2.5 mg to be taken twice daily for atrial fibrillation. However, the plan of care for R22 did not include interventions to monitor for signs and symptoms of bleeding and bruising, which are potential side effects of anticoagulant medication. This deficiency was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that the plan of care lacked necessary monitoring for anticoagulant side effects.
Failure to Monitor Adverse Effects of Psychotropic Medications
Penalty
Summary
The facility did not ensure proper monitoring for adverse effects of psychotropic medications for three residents. Resident 16 was prescribed multiple psychotropic medications, including antipsychotic, antidepressant, and anti-anxiety medications. The medical record did not indicate that a gradual dose reduction (GDR) was attempted within the last year or that a GDR was contraindicated. Despite requests from the surveyor, the facility did not provide documentation to support the absence of a GDR attempt or contraindication for Resident 16's medications. Resident 128, who had diagnoses including dementia and anxiety, was prescribed antipsychotic, antidepressant, and anti-anxiety medications. The resident's care plan did not include monitoring for signs and symptoms of adverse effects or the effectiveness of the medications. Additionally, the medical record did not contain an Abnormal Involuntary Movement Scale (AIMS) assessment. The Director of Nursing confirmed that an AIMS assessment was not completed upon admission and that monitoring for adverse effects was not documented in the care plan or Treatment Administration Record (TAR). Resident 178, diagnosed with mild neurocognitive disorder with behavioral disturbance, was prescribed antipsychotic and anti-anxiety medications. The resident's care plan did not include monitoring for adverse effects or the effectiveness of the medications, and the medical record did not contain an AIMS assessment. The AIMS assessment and monitoring orders were only completed after the surveyor's request, indicating a lack of prior monitoring. The Director of Nursing verified that these assessments and monitoring orders were not in place before the surveyor's intervention.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility did not ensure the minimum required members of the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly, impacting all 27 residents. Three of four required quarterly QAPI meetings held over the past year did not have the Medical Director (MD), Nursing Home Administrator (NHA), Director of Nursing (DON), and/or Infection Preventionist (IP) in attendance as required. Specifically, the QAPI meeting on 6/14/23 included the NHA, DON, IP, and seven other staff; the meeting on 9/13/23 included the MD, NHA, DON, IP, and five other staff; the meeting on 12/13/23 included the NHA and five other staff; and the meeting on 3/13/24 included the DON/IP and five other staff. The NHA confirmed that the MD attended only one meeting in person during the last year and was expected to attend and participate at least quarterly as required.
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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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