Sheridan Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kenosha, Wisconsin.
- Location
- 8400 Sheridan Rd, Kenosha, Wisconsin 53143
- CMS Provider Number
- 525318
- Inspections on file
- 29
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Sheridan Health And Rehabilitation Center during CMS and state inspections, most recent first.
Multiple incidents occurred where residents were subjected to abuse or threats of abuse, including inappropriate touching, verbal threats of sexual assault, physical altercations with racial slurs, and verbal abuse by an agency CNA. These events involved both cognitively impaired and intact residents, as well as staff, and were confirmed by facility staff and documented in misconduct reports.
The facility did not consistently report allegations of abuse, neglect, or theft to the State Agency or law enforcement within required timeframes. In several cases, including verbal abuse and suspected theft involving cognitively intact residents, reports were delayed or not made, and law enforcement was not notified as required by facility policy.
The facility did not complete thorough investigations into multiple abuse allegations, including inappropriate touching between residents, verbal threats of sexual assault, and claims of staff verbal abuse. In each case, the facility failed to promptly investigate or notify law enforcement, despite policy requirements, and delayed action after receiving reports from both residents and external sources.
A resident with multiple chronic conditions was no longer permitted to self-administer medications due to repeated non-compliance, including hoarding and improper dosing. Despite this change, the care plan was not updated to reflect the new status, and staff interviews confirmed the oversight.
A facility failed to inform a resident's family member of care conferences in advance, impacting their ability to participate in care planning. The resident, who was cognitively intact, wanted her family involved, but the family member only received a last-minute call about a conference. The Social Services Director admitted there was no system to track invitations, and the Director of Nursing expected family members to be informed in advance.
A resident with paraplegia and functional limitations in a long-term care facility did not receive necessary nail care, as his care plan did not address this need and staff failed to offer assistance. Despite being cognitively intact, the resident's nails were long and thick, requiring staff intervention. The DON suggested it was the resident's responsibility to request nail care, and the CNA was unsure if the resident had been asked about his needs. Eventually, staff had to soak the resident's nails to trim them.
The facility failed to provide timely pressure ulcer treatments for two residents, leading to a delay in care. One resident did not receive treatment for several days after admission due to delayed implementation of orders. Another resident's wound vac system was not applied promptly, and interim dressings were used without proper orders. The DON confirmed these deficiencies, highlighting issues in timely care and documentation.
A resident with a feeding tube did not receive appropriate care, leading to potential infection risks. The facility failed to label and change enteral feeding and water flush bags, as well as the syringe and container, every 24 hours. The resident's feeding tube insertion site had not been cleaned or the dressing changed as required, and the feeding pump was not regularly cleaned. These deficiencies were confirmed by the Unit Manager and DON.
The facility failed to provide necessary medications for two residents, leading to unmanaged pain and delayed antibiotic treatment. A resident did not receive prescribed pain medication due to reordering failures, while another experienced a 22-hour delay in receiving an IV antibiotic after admission. Staff interviews revealed issues with communication and medication ordering processes, impacting resident care.
A resident reported that meals, especially breakfast, were served lukewarm, despite having good flavor. A test tray confirmed the food temperature was too low for palatability. The Dietary Manager acknowledged complaints and noted issues with meal delivery speed and equipment, despite the holding temperature being adequate.
An LPN in an LTC facility failed to follow infection control protocols by taking a treatment cart into a resident's room during pressure ulcer care and returning unused supplies to the cart, risking cross-contamination. The DON confirmed this practice was a concern and that supplies should have remained in the room.
A resident with hearing loss was not provided with a care plan addressing their refusal to wear hearing aids, leading to communication challenges. Despite staff awareness of the issue, no interventions were documented in the care plan or CNA Kardex. The DON acknowledged the oversight in care planning for the resident's hearing needs.
A resident with a complex medical history was prescribed Ativan on a PRN basis without an end date, contrary to the facility's policy on managing drug regimens. The oversight was identified during a survey, and the DON acknowledged the error.
The facility failed to maintain a medication error rate below 5 percent, affecting two residents. One resident received levothyroxine after breakfast and expired Timolol Maleate eye drops. Another resident was given immediate release Venlafaxine instead of the prescribed extended release form due to unavailability. These errors resulted in a medication error rate of 10.71 percent.
A resident was administered 150 mg of immediate release Venlafaxine instead of the prescribed extended release form due to a lack of the correct medication in the backup supply. An LPN, instructed to use immediate release tablets, gave five 37.5 mg tablets to the resident. The error was identified during a surveyor's observation, and the LPN planned to contact the resident's doctor immediately. The Nursing Home Administrator and DON were informed, but no further explanation was provided.
The facility employed an unqualified Food Service Manager (FSM) for 52 of 53 residents, lacking the required certification and experience. The FSM admitted to not having started the necessary certification course since starting the position, and the Administrator was unaware of this deficiency.
The facility failed to provide written transfer notices to two residents and their representatives during emergent hospital transfers, as required by policy. Despite the policy's clear guidelines, the facility's practice involved only verbal communication and documentation for emergency services, without providing the necessary written notice to the residents or their representatives. This oversight was confirmed through staff interviews, revealing a lack of awareness about the requirement.
The facility failed to follow physician orders for weight monitoring for three residents, leading to potential unrecognized weight changes. Despite having complex medical conditions, weights were not recorded as required. Interviews with staff confirmed the expectation to comply with orders, indicating a lapse in adherence to the facility's weight monitoring policy.
Failure to Prevent Resident-to-Resident and Staff-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from various forms of abuse, including physical, verbal, and sexual abuse, as well as neglect, as evidenced by multiple incidents involving both resident-to-resident and staff-to-resident interactions. In one case, a cognitively intact resident reported that a severely cognitively impaired resident inappropriately touched her breast on two occasions during hugs, with the second incident perceived as intentional. The resident stated she would no longer allow the other resident to hug her, and no further incidents were reported. Another incident involved a severely cognitively impaired resident who was verbally threatened with sexual assault by another cognitively intact resident during care provided by CNAs. The threatening resident made repeated inappropriate comments and threats in the presence of staff. Additionally, a physical and verbal altercation occurred between two cognitively intact residents in the courtyard, where racial slurs were exchanged, and both residents engaged in physical aggression, resulting in one resident being slapped and the other being hit in the face. Both residents declined to press charges after the incident was reported to the police. A separate event involved an agency CNA who was overheard by an LPN yelling at a cognitively intact resident, instructing her to roll over by herself in a loud and inappropriate manner. The LPN intervened, removed the CNA from the room, and escorted her out of the facility. The resident denied any physical harm but confirmed the verbal abuse. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was confirmed that these incidents constituted failures to prevent and prohibit all types of abuse as required.
Failure to Timely Report Abuse, Neglect, or Theft Allegations
Penalty
Summary
The facility failed to ensure that reportable allegations of abuse, neglect, or theft were reported to the State Agency (SA) in a timely manner and did not notify law enforcement as required. In one instance, a cognitively intact resident with multiple medical conditions was subjected to verbal abuse by a CNA, which was witnessed by an LPN. Although the CNA was immediately removed from the facility and the Administrator and DON were contacted, the mandated 24-hour report to the SA was not submitted until five days after the incident. The Administrator attributed the delay to system issues with the State's online reporting portal and did not notify law enforcement. In another case, a cognitively intact resident reported missing cash after staff returned money that had been given to them. The incident was reported to the SA, but law enforcement was not notified, as the Administrator was unaware of the requirement to do so when a crime is suspected. Additionally, a third cognitively intact resident reported feeling verbally abused by staff, with the information coming from a hospital assessment. The Administrator investigated the incident but did not report it to the SA, believing it was unnecessary since the resident had not reported it directly to the facility. The facility's policy required immediate reporting of all alleged violations to the Administrator, SA, adult protective services, and law enforcement when applicable, but these procedures were not consistently followed.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into abuse allegations involving three residents. In the first case, a cognitively intact resident reported that another resident with severe cognitive impairment touched her breast on two occasions, with the second incident perceived as intentional. The incident was reported to staff, but the facility did not complete a comprehensive investigation or contact law enforcement, as required by policy. In the second case, a resident with paraplegia made sexually inappropriate threats toward a severely cognitively impaired resident in the presence of staff. Although staff intervened verbally, the facility did not conduct a thorough investigation or notify the police, citing the residents' lack of desire to press charges as the reason for inaction. In the third case, a cognitively intact resident reported to hospital staff that he felt verbally abused and intimidated by facility staff. The facility received this information soon after the resident's hospital admission but did not initiate a timely investigation, with the administrator stating the investigation occurred over a week after learning of the allegation. These failures to promptly and thoroughly investigate abuse allegations, as well as to notify appropriate authorities, were contrary to the facility's own policies and procedures.
Failure to Update Care Plan After Change in Medication Self-Administration Status
Penalty
Summary
The facility failed to revise the care plan for one resident after a change in the resident's medication self-administration status. The resident, who had multiple diagnoses including end stage renal disease, asthma, type 2 diabetes mellitus, and a history of sudden cardiac arrest, was previously permitted to self-administer medications as documented in the care plan. However, after repeated incidents of non-compliance, such as hoarding medications, leaving them at the bedside, and not taking them as scheduled, the DON determined it was no longer safe for the resident to self-administer medications. This decision was supported by a self-administration evaluation indicating the resident was not safe to self-administer medications. Despite this change, the care plan was not updated to reflect the resident's new status. Interviews with the resident, DON, and Administrator confirmed that the care plan continued to state the resident could self-administer medications, and no updated care plan was found. The DON acknowledged responsibility for revising the care plan and admitted the update was missed during the most recent quarterly review.
Failure to Inform Family of Care Conferences
Penalty
Summary
The facility failed to inform a family member of care conferences and provide sufficient notice in advance for a resident's care planning. The facility's policy requires that residents' choices in individuals to be included in the care planning process be honored, and efforts should be made to schedule conferences at convenient times for the resident or their representative. However, there was no documented evidence that the resident's family member was invited to participate in the development of the initial care plan or informed in advance of subsequent care conferences. The resident, who was cognitively intact, expressed a desire for her family member to be involved in all aspects of her care. The family member reported receiving a last-minute phone call from the Social Services Director about a care plan conference, which was the only invitation she had received. The Social Services Director admitted there was no system to track invitations to family members and acknowledged that the family member was not informed in advance of the care conference. The Director of Nursing stated that it was expected for family members to be invited in advance to care plan conferences.
Failure to Provide Nail Care to Resident with ADL Deficit
Penalty
Summary
The facility failed to provide necessary nail care to a resident who was unable to perform this activity of daily living independently. The resident, who was admitted with paraplegia and had functional limitations in both upper and lower extremities, was dependent on staff for personal hygiene. Despite being cognitively intact, the resident's care plan did not specifically address nail care, and the facility's policy on nail care was not followed. The resident's fingernails extended approximately one-half inch beyond the tips of his fingers and appeared thick, indicating a need for staff assistance in trimming them. During observations and interviews, it was revealed that the resident had not been offered nail care by the staff, and the Director of Nursing suggested that it was the resident's responsibility to request nail care due to his alert and oriented status. The Certified Nurse Aide mentioned that nail care was typically provided on shower days but was unsure if the resident had been asked about his nail care needs. The resident expressed a lack of knowledge on how to get his nails trimmed and stated that no staff member had offered assistance. Eventually, staff had to soak the resident's nails to soften them for trimming, indicating a delay in addressing the resident's personal hygiene needs.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were ordered and provided for two residents, R12 and R2, which put them at risk for deterioration of their pressure ulcers. For R12, the facility received wound care orders from the hospital upon the resident's admission, but these orders were not implemented until several days later. The Assistant Director of Nursing (ADON) received the treatment orders from the Medical Director but delayed their implementation, resulting in a lack of treatment for R12's pressure ulcers until five days after admission. For R2, the facility did not apply the prescribed wound vacuum (wound vac) system for the resident's pressure ulcer treatment in a timely manner. Although the wound vac was delivered to the facility, it was not applied until three days later. In the interim, a wet to dry dressing was applied without a physician's order, and there was no documented evidence of any wound treatment on one of the days before the wound vac was started. The Unit Manager (UM) confirmed the delay and the lack of proper orders for the interim dressing. The Director of Nursing (DON) confirmed the deficiencies in both cases, acknowledging the lack of timely implementation of treatment orders and the absence of proper documentation for the interim dressing applied to R2. These failures highlight the facility's inability to provide timely and appropriate pressure ulcer care for the residents, as evidenced by the lack of documented treatment and the delay in implementing physician orders.
Inadequate Care for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a feeding tube, which had the potential to increase the risk of infection. The resident, who was cognitively intact and required tube feeding due to dysphagia, did not have physician orders for the care and treatment of the feeding tube insertion site. Observations revealed that the enteral feeding and water flush bags were not labeled with the date, time, or initials of the person who prepared them, contrary to the facility's policy and current standards of practice. During an observation, it was noted that the resident's feeding tube insertion site had a dressing dated two days prior, with areas of dried blood, indicating that the site had not been cleaned or the dressing changed as required. The Unit Manager confirmed that the dressing should be changed every night, but it had not been done. Additionally, the syringe and container used for the feeding tube were also dated two days prior, despite the requirement for daily changes. The Director of Nursing confirmed that the failure to label and change the enteral feeding and water flush bags, as well as the syringe and container, every 24 hours was an infection control concern. Furthermore, the feeding pump had a build-up of dried enteral feeding formula, and there was uncertainty about the responsibility for cleaning the pump, which should be done regularly. These oversights in care and maintenance of the feeding tube and related equipment contributed to the deficiency identified by the surveyors.
Medication Availability Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure the availability of medications for two residents, leading to significant deficiencies in care. Resident 5, who was admitted with conditions including spondylosis and polyosteoarthritis, underwent outpatient surgery for a left ankle bone infection. Despite a physician's order for hydrocodone-acetaminophen to manage post-operative pain, the resident did not receive the medication as prescribed. On multiple occasions, the resident was given only one tablet instead of the ordered two, and eventually ran out of medication entirely. The resident reported severe pain and was unable to enjoy activities due to the lack of pain management. The facility's Director of Nursing acknowledged that the medication should have been available from the contingency box, indicating a failure in the medication reordering process. Resident 2, admitted with diagnoses including an open wound and chronic osteomyelitis, was prescribed cefepime, an antibiotic, to be administered intravenously. However, the resident did not receive the first dose until 22 hours after admission, and 31 hours after the last dose was administered at the hospital. The delay was attributed to the medication not being available in the facility's contingency kit and issues with the pharmacy delivery schedule. The Director of Nursing confirmed that new admissions typically do not receive medications until the following day, and there was a lack of clarity regarding the facility's ability to order medications for immediate delivery. Interviews with staff revealed a lack of communication and coordination in the medication ordering process. Licensed Practical Nurses and the Unit Manager indicated that there were contingency measures in place for obtaining medications, but these were not effectively utilized. The Director of Nursing admitted that the facility had the capability to order medications for stat delivery, but this was not executed in a timely manner for Resident 2. The deficiencies highlight significant lapses in the facility's medication management system, impacting the residents' care and comfort.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature for a resident, identified as R5, who was reviewed for food palatability. R5, who was cognitively intact, reported that meals, particularly breakfast, were served lukewarm and bordered on being cold, despite having good flavor. R5 had made multiple complaints about the food temperatures. During an observation, a test tray of biscuits and gravy was served 15 minutes after the food cart was delivered, and the temperature was measured at 110 degrees Fahrenheit, which was confirmed by the Dietary Manager (DM) to be too low for palatability. The facility's policy on food preparation emphasized serving food at a safe and appetizing temperature. However, the DM acknowledged that residents had complained about food temperatures and noted that the insulated cover used for meal delivery might not be sufficient. The DM also mentioned that sometimes staff did not deliver meal trays quickly enough, contributing to the problem. The holding temperature for the breakfast meal was recorded at 180 degrees Fahrenheit, indicating that the issue arose during the delivery process rather than food preparation.
Infection Control Breach During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during the treatment of a pressure ulcer for a resident diagnosed with paraplegia and a pressure ulcer of unspecified site. During an observation, an LPN was seen taking a treatment cart into the resident's room and placing unused supplies back into the cart after completing the treatment. The supplies included a bottle of Dakin's solution, gauze pads, a tube of Santyl, and foam bordered dressings. This practice posed a risk of cross-contamination as the supplies were exposed to the resident's environment and then returned to the cart without proper sanitization. The LPN admitted to occasionally taking the treatment cart into the room to keep supplies tidy, although she acknowledged that the supplies had not been opened. The Director of Nursing confirmed that this practice was an infection control concern and that the supplies should have been left in the resident's room to prevent potential cross-contamination. The DON also stated that she had not previously observed the LPN engaging in this practice.
Failure to Address Resident's Hearing Loss in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing a resident's hearing loss, as observed during a survey. The resident, who was admitted with diagnoses including urinary tract infection, moderate protein-calorie malnutrition, disease of the pericardium, and anemia, was noted to have intact cognition and required assistance with dressing. Despite being assessed as having hearing aids and adequate hearing, the resident reported not wearing the aids because they were disliked and ineffective. The surveyor observed that staff had to speak directly into the resident's ear for effective communication, indicating a gap in the care plan. Interviews with facility staff, including CNAs and the ADON, revealed that the resident's refusal to wear hearing aids was known, but no care plan or interventions were in place to address this issue. The CNA Kardex also lacked guidance on how to communicate with the resident effectively. The DON acknowledged the oversight in initiating a care plan for the resident's hearing loss and hearing aids, which contributed to the deficiency noted by the surveyor.
Resident Prescribed PRN Ativan Without End Date
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications ordered on an as-needed (PRN) basis. Specifically, a resident was prescribed Ativan, an anti-anxiety medication, to be taken every eight hours as needed, without an end date. This oversight was identified during a surveyor's review of the resident's physician orders, which revealed the absence of a specified duration for the PRN medication. The resident in question had a complex medical history, including traumatic hemorrhage of the cerebrum, chronic respiratory failure, chronic obstructive pulmonary disease, schizophrenia, major depressive disorder, and anxiety. Despite these conditions, the facility's policy mandates that each resident's drug regimen be managed to promote their highest practicable well-being, free from unnecessary drugs. The director of nursing acknowledged the oversight when it was brought to their attention by the surveyor, indicating that the lack of an end date for the PRN Ativan was an error.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as observed during a survey. Two residents were affected by medication administration errors. One resident, diagnosed with hypothyroidism and glaucoma, was administered levothyroxine after breakfast instead of on an empty stomach, contrary to medication guidelines. Additionally, the same resident received Timolol Maleate eye drops that were not discarded four weeks after opening, as per the manufacturer's instructions. These errors were observed during a medication administration session by an LPN. Another resident, diagnosed with depression, was administered 150 milligrams of immediate release Venlafaxine instead of the prescribed 150 milligrams of extended release Venlafaxine. The LPN administering the medication did not have the extended release tablets available and was instructed to use immediate release tablets from the backup supply. This resulted in the resident receiving a total of five 37.5 milligram tablets of immediate release Venlafaxine. The LPN acknowledged the error and indicated that the resident's doctor would be contacted immediately. These incidents contributed to a medication error rate of 10.71 percent, exceeding the acceptable threshold.
Medication Error: Immediate vs. Extended Release Venlafaxine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident, identified as R24, was administered 150 milligrams of Venlafaxine immediate release instead of the prescribed 150 milligrams of extended release Venlafaxine. This error occurred when an LPN, identified as LPN-D, administered the medication. The LPN initially poured 37.5 milligrams of Venlafaxine from the resident's medication card and, upon realizing the absence of the extended release tablets in the backup supply, was instructed to give additional immediate release tablets to make up the total dosage. Consequently, the LPN administered five 37.5 milligram tablets of immediate release Venlafaxine to the resident. The resident, R24, had been admitted to the facility with a diagnosis of depression and had a physician's order for Venlafaxine extended release 150 milligrams once daily. The error was identified during a surveyor's observation and subsequent review of the resident's current physician orders. The LPN acknowledged the error and indicated that she would contact the resident's doctor immediately. The Nursing Home Administrator and Director of Nurses were informed of the findings, but no additional information was provided regarding the reason for administering the incorrect form of Venlafaxine.
Unqualified Food Service Manager Employed
Penalty
Summary
The facility failed to employ a qualified full-time Food Service Manager (FSM) with the required certification and skill sets for 52 of 53 census residents. The job description for the FSM position requires a graduate of an accredited course in dietetic training approved by the American Dietetic Association, with a minimum of two years' experience in a supervisory capacity in a hospital, nursing care facility, or other related medical facility, and training in cost control, food management, and diet therapy. However, during an interview, the FSM admitted to not having started the necessary certification course since beginning the position in October 2023. Additionally, the FSM's resume did not reflect any food management positions or experience. The Administrator was unaware of the FSM's lack of training and acknowledged that the FSM should have had the required training before being hired.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to two residents and their representatives during emergent hospital transfers. The policy requires that such notices include specific reasons for the transfer, the effective date, the location of transfer, and information on appeal rights. However, upon review of the electronic medical records for two residents, there was no evidence that these notices were provided during their hospital transfers. This oversight was confirmed through interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who were unaware of the requirement to provide written notices to residents and their representatives. The deficiency was identified during a review of the facility's policy and procedures, which clearly state the necessity of providing written notices in a language and manner understandable to the resident and their representative. Despite this policy, the facility's practice during emergent transfers involved only verbal communication and documentation for emergency services, without providing the required written notice to the residents or their representatives. This lack of compliance with the policy was evident in the cases of two residents who were transferred to the hospital without receiving the necessary documentation, leaving them and their representatives uninformed about the transfer details and their rights to appeal.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to ensure physician orders for weight monitoring were followed for three residents, which could lead to unrecognized significant weight changes due to the lack of established baseline weights. The facility's policy required weekly weight monitoring for newly admitted residents for four weeks. However, for Resident 2, weights were only recorded on two occasions, missing the required weekly checks. Resident 2 had multiple diagnoses, including hemiplegia, congestive heart failure, and obesity, which necessitated careful monitoring. Similarly, Resident 30's weight records showed inconsistencies, with weights taken on non-consecutive weeks, failing to adhere to the weekly schedule. Resident 30 had complex medical conditions such as morbid obesity, end-stage renal disease, and hypertension. For Resident 32, only one weight was recorded during the specified period, despite having conditions like heart failure and acute kidney failure. Interviews with staff, including an LPN and the DON, confirmed the expectation that weights should be taken as ordered, highlighting a lapse in compliance with physician directives.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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