St Elizabeth Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Janesville, Wisconsin.
- Location
- 109 S Atwood Avenue, Janesville, Wisconsin 53545
- CMS Provider Number
- 525639
- Inspections on file
- 28
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at St Elizabeth Nursing Home during CMS and state inspections, most recent first.
The facility failed to maintain safe, clean, and sanitary resident bathrooms, resulting in multiple shared bathrooms with strong urine odors, dried urine on floors, urine and toilet paper left in toilets, and feces on toilet chairs, toilet rims, and toilet walls. A CNA confirmed the bathrooms were not clean and stated that housekeeping was responsible, while also noting there was only one housekeeper handling both housekeeping and laundry. The housekeeper reported being unable to complete all duties and indicated there was no checklist or schedule for room cleaning, despite an expectation that rooms be cleaned daily. Maintenance, which oversaw housekeeping, acknowledged there were no formal cleaning schedules and that resident rooms were cleaned only twice a week, and agreed the observed bathrooms were not clean. The DON stated that bathrooms and floors should be cleaned daily and that CNAs should tidy and pick up bathroom messes before housekeeping sanitizes, but acknowledged awareness that the bathrooms were not clean.
The facility failed to maintain an effective infection prevention and control program, affecting all residents. Key staff were unaware of their roles in the Water Management Plan, and control measures for Legionella were not documented. Immunization protocols were outdated, lacking the latest CDC guidance. Infection control rates were not calculated for the past year, indicating a lack of routine monitoring and analysis.
A facility failed to update a resident's advance directive in a timely manner. The resident's POA initially signed a DNR form, but after a hospital stay, the family revoked the DNR and requested full code status. Despite informing the staff, the necessary documentation was not completed immediately, leading to a delay in updating the resident's medical record.
The facility failed to conduct sleep assessments and monitoring for three residents receiving Melatonin for sleep, despite their medical and cognitive conditions. The Director of Nursing confirmed that the protocol requires such assessments and tracking, but it was not completed for these residents.
A resident's motorized wheelchair was improperly charged in her room, contrary to facility policy requiring charging in the Beauty Shop. The NHA, DON, and a CNA confirmed the policy, noting the resident was the only one with such a device. The DON initiated staff education to address the issue.
A resident experienced inadequate pain management due to the facility's failure to provide scheduled pain patches and assess pain goals. The resident's pain was not effectively managed, leading to missed physical therapy sessions. Facility staff did not adhere to policies for medication availability and documentation, and the resident's care plan lacked specific pain goals and non-pharmacological interventions.
A resident did not receive prescribed Lidocaine patches on multiple occasions due to unavailability, resulting in medication errors. Despite having a process for handling unavailable medications, staff interviews revealed inconsistencies in following procedures, such as accessing contingency stock and documenting missed doses. The resident's chronic pain condition was not adequately managed, as the facility failed to ensure the medication was administered as ordered.
Two residents in an LTC facility were found to be receiving psychotropic medications without proper monitoring. One resident was given a PRN anti-anxiety medication beyond the allowed 14-day period without physician follow-up, and another resident did not receive the required AIMS assessment for antipsychotic medication monitoring. Interviews with staff confirmed these deficiencies.
The facility did not update or implement its COVID-19 Vaccine policy for two residents, failing to offer the 2024-2025 vaccine as per CDC guidelines. One resident with dementia and a history of stroke, and another with chronic heart and lung conditions, were not offered the vaccine, despite the Director of Nursing acknowledging they should have been.
A resident with a UTI caused by Enterobacter cloacae complex and MRSA was prescribed Cefdinir, which is ineffective against MRSA. The facility failed to obtain the urinalysis culture and sensitivity results from the hospital, leading to inappropriate antibiotic treatment. The resident's condition worsened, resulting in hospitalization for sepsis and requiring intravenous antibiotics and fluids. The facility acknowledged the lack of follow-up as a deficiency in their antibiotic stewardship process.
A resident with chronic conditions experienced multiple instances of hypotension, but the facility failed to notify a physician as required by policy and discharge orders. Despite guidelines indicating immediate notification for blood pressure below 90, no documentation showed physician contact. Interviews confirmed that discharge orders should have been treated as physician orders, and a full RN assessment and notification should have occurred.
A resident with CHF was not weighed regularly due to the absence of a physician order, despite facility policy and discharge transfer orders indicating the need for weight monitoring. The facility lacked a standard practice for weighing residents, relying solely on physician orders. The DON and RN acknowledged the oversight, and the NP did not respond to inquiries about care expectations.
A facility failed to label a Humalog (Lispro) vial with a resident's name, as observed during insulin administration. The Medication Technician administered the insulin from an unlabeled vial, assuming it belonged to the resident. The facility's policy requires medications to be labeled and verified using the Five Rights principle, which was not followed. The resident had multiple diagnoses, including diabetes mellitus type 2 and dementia. Both the LPN and DON acknowledged the labeling requirement for medications pulled from contingency.
Two residents experienced harm due to the facility's failure to provide appropriate wound care and treatment. One resident with diabetes had a wound that was not properly assessed or treated, leading to infection and amputation. Another resident suffered a burn from undiluted Tea Tree Oil, resulting in infection and hospitalization. The facility did not adhere to professional standards, failing to conduct timely assessments and notify providers of changes in condition.
The facility did not ensure adequate nursing staff to meet resident needs, resulting in long call light wait times and incomplete care tasks. Two residents reported waiting over an hour for assistance, particularly during PM shifts. Staff confirmed frequent call-ins and inadequate staffing levels based on a grid that did not consider resident acuity. The new administration plans to address these issues.
The facility did not maintain an up-to-date facility-wide assessment to determine necessary resources for resident care during daily operations and emergencies. The existing assessment from December 2022 was outdated and did not reflect the current resident population or required resources. The NHA initially provided a PowerPoint presentation instead of a proper assessment, and later acknowledged the need for an accurate and updated assessment.
The facility did not perform daily diabetic foot checks for four residents as required by its diabetes care protocol. Despite having conditions like diabetes mellitus type 2 and neuropathy, there was no documentation to show these checks were completed. The Director of Nursing confirmed the lack of records, highlighting a failure to adhere to the facility's standards for diabetic foot care.
A facility failed to conduct a thorough investigation of an abuse allegation involving a CNA and a resident. Despite the ongoing investigation, the CNA was allowed to return to work before its completion, without obtaining a statement from the CNA or conducting additional interviews. The facility's actions were inconsistent with its policy, leading to a deficiency in handling abuse allegations.
The facility failed to provide appropriate catheter care and monitoring for three residents with indwelling catheters. Two residents had outdated physician orders for monthly catheter changes, contrary to CDC guidelines, and their urine output was not monitored as required. Another resident had conflicting orders for catheter sizes. Staff interviews revealed inconsistencies in urine output documentation, with only one resident having proper orders in the electronic medical record.
Three residents were found to be receiving psychotropic medications without appropriate diagnoses or indications. One resident was prescribed Quetiapine for agitation/anxiety, and another for dementing illness with behaviors, neither of which are appropriate indications for antipsychotics. A third resident was receiving Citalopram and had been on Haldol without specified diagnoses in the physician orders. The facility lacked documentation and consents for these medications, as acknowledged by the DON.
Three residents in an LTC facility experienced significant medication errors. A resident missed a dose of Apixaban due to unavailability, and the physician was not notified. Another resident missed two doses of Insulin Glargine without documented parameters or physician orders to hold the medication. A third resident had multiple missed doses of insulin and anticoagulant without valid physician orders or notification. The DON confirmed these were medication errors and acknowledged the lack of signed physician orders.
The facility did not ensure an RN was on duty for 8 consecutive hours daily, as required. On two specific days, the facility lacked RN coverage for the mandated duration, confirmed by the ADON. This deficiency potentially affects all 32 residents.
The facility failed to provide social service assistance for four residents, resulting in missed care conference meetings due to the absence of a social worker. This affected the facility's ability to ensure person-centered care and prioritize resident goals. Residents did not have their required care conferences, impacting their care planning and goal setting.
The facility did not ensure that two residents were assessed for the safe self-administration of medications. One resident was found with medication at her bedside without a completed assessment, and the DON confirmed she was not able to safely self-administer. Another resident reported that staff leave medications on her bedside table, but no assessment was documented. The facility's policy requires an assessment and prescriber's order for self-administration, which was not followed.
A facility failed to investigate an alleged verbal abuse incident between two residents, where one resident repeatedly yelled at another during meals due to a medical condition causing coughing. Despite staff awareness and acknowledgment of potential abuse, no formal investigation was conducted, and the situation was believed to have resolved itself by separating the residents. The facility's policy requires thorough investigation and intervention, which was not followed.
A resident with multiple diagnoses expressed a desire to return home, but the facility failed to develop a safe discharge plan. Despite staff awareness of the resident's intentions, the care plan lacked updates and interventions since 2022. The resident left without necessary medications or community supports, as the facility had been without a social worker for months, leading to an unsafe discharge.
A resident with multiple health conditions did not receive a shower for two weeks due to the facility's failure to provide necessary personal hygiene care. The resident's care plan lacked specific instructions for bathing assistance, and staff interviews revealed missed showers due to staffing issues and inadequate documentation. The facility did not follow procedures for documenting and communicating missed showers, resulting in a deficiency in care.
A resident with a C. diff infection was not placed on isolation precautions upon admission, contrary to CDC guidelines and facility policy. The oversight occurred due to an incomplete admission process during a shift change, and isolation was only implemented days later after staff reviewed the resident's medication and hospital notes. The DON confirmed the delay in initiating contact precautions.
A facility failed to notify a physician when a resident left against medical advice (AMA), as required by policy. The resident was discharged AMA with a family member, but the progress notes showed no evidence of physician notification. Interviews with the Executive Director and an LPN confirmed the oversight.
A resident reported that a family member was taking their money to buy drugs. The facility's policy requires immediate reporting of such allegations, but the Executive Director was not informed until two days later, and the state agency was notified even later. The Executive Director admitted to reporting outside the required period, leading to a deficiency in timely reporting.
A resident with a history of surgical amputation and osteomyelitis was discharged without arranged home health services, despite facility policy requiring such arrangements. The resident was not contacted by home health services post-discharge, and the ADON admitted that referrals were not made until the resident reached out. The ED and DON confirmed the nursing team's responsibility for discharge referrals, but it was unclear if this was fulfilled.
Unsanitary Resident Bathrooms and Lack of Housekeeping Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, specifically related to unsanitary resident bathrooms and the absence of housekeeping policies and procedures. Surveyor observations on 2/3/26 found that four of four inspected bathrooms serving seven residents had strong urine odors, dried urine on floors, urine and toilet paper left in toilets, and feces on toilet chairs, toilet rims, and toilet walls. In one shared bathroom, there was dried urine and feces on the toilet chair and rim, and dried urine on the floor. Another resident’s bathroom had feces on the toilet chair, toilet rim, and inside walls of the toilet. A third shared bathroom had a strong urine odor, dried urine on the floor, feces on the back of the toilet chair, and urine and toilet paper in the toilet. A fourth shared bathroom had a strong urine odor, urine and toilet paper in the toilet, dried urine on the floor, and toilet paper on the floor saturated with dried urine. The facility did not have a housekeeping policy or procedure in place, as confirmed by the Nursing Home Administrator. The CNA who accompanied the surveyor acknowledged that the bathrooms were not clean and stated that housekeeping was responsible for cleaning resident rooms, noting that there was only one housekeeper for both housekeeping and laundry. The housekeeper reported being unable to complete both housekeeping and laundry duties alone and stated there was no checklist or schedule for cleaning resident rooms, although each room was supposed to be cleaned daily. The maintenance staff member overseeing housekeeping confirmed there were no hard schedules, checklists, or calendars for room cleaning, stated that resident rooms were cleaned twice a week, and agreed that the observed bathrooms were not clean. The DON stated that bathrooms and floors should be cleaned daily and that CNAs were responsible for tidying and picking up bathroom messes before housekeeping sanitized, but acknowledged awareness that the bathrooms were not clean.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which could potentially affect all 33 residents. The Water Management Plan team members, including the Director of Nursing/Infection Preventionist (DON/IP) and the Facility Service Manager (FSM), were unaware of their roles and responsibilities. Control measures to prevent Legionella were not routinely completed or documented, and there was no monitoring of water heater temperatures or circulation pumps. Additionally, the facility's policies and procedures were not reviewed annually as required. The facility's immunization protocols were outdated and did not reflect the most recent CDC guidance for COVID-19 and pneumococcal vaccinations. The DON/IP was not familiar with the latest updates, and the facility's policies did not include the newest information. This lack of updated protocols could lead to residents not receiving the appropriate vaccinations as recommended by the CDC. Furthermore, the facility did not calculate infection control rates for the past year, which are essential for tracking and trending infections over time. The DON/IP only provided infection control documentation upon the surveyor's request, indicating a lack of routine monitoring and analysis of infection data. This deficiency in infection control practices highlights significant gaps in the facility's ability to prevent and manage infections effectively.
Failure to Update Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive was properly updated and signed by the resident's representative. The resident, who was incapacitated prior to admission, had a Power of Attorney (POA) who initially signed a form indicating a Do Not Resuscitate (DNR) status. However, after a hospital stay, the family decided to revoke the DNR and requested a change to full code status, indicating the resident wanted cardiopulmonary resuscitation (CPR). The POA informed the facility staff of the change in code status shortly after the resident returned from the hospital. Despite the POA's communication and assurance from the staff that the update was made, the necessary documentation was not completed at that time. The Assistant Director of Nursing later provided a signed Resident CPR Preference Form, but it was dated after the initial request for the change, indicating a delay in updating the resident's medical record to reflect the new code status preference.
Failure to Conduct Sleep Assessments and Monitoring for Residents on Melatonin
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for three residents who were receiving Melatonin for sleep. Specifically, the facility did not conduct sleep assessments or implement sleep monitoring/tracking for these residents, which is necessary to meet their medical, nursing, and mental and psychosocial needs. The deficiency was identified during a survey where the surveyor requested documentation of sleep assessments and monitoring for the residents, but the facility was unable to provide it. Resident 8, who is cognitively intact, was admitted with diagnoses including depression, insomnia, anxiety disorders, and panic disorder. Resident 15, with severe cognitive impairment, was admitted with unspecified dementia and insomnia due to another mental disorder. Resident 30, with moderate cognitive impairment, was admitted with Alzheimer's Disease and dementia with behavioral disturbance. Despite these conditions and the administration of Melatonin, the facility did not complete the necessary sleep assessments or tracking. The Director of Nursing confirmed that the facility's protocol requires sleep assessments and tracking for residents on sleep medications, but acknowledged that this was not done for the residents in question.
Improper Charging of Motorized Wheelchair in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards, as evidenced by the improper charging of a motorized wheelchair in a resident's room. The facility's policy, reviewed on November 8, 2023, clearly states that batteries for motorized assistive devices must be charged in a non-resident approved area, specifically the Beauty Shop. However, on February 11, 2025, a surveyor observed the motorized wheelchair of a resident, identified as R8, being charged in her room next to her bed while she was sleeping. This was contrary to the facility's policy and posed a potential hazard. Interviews with the Nursing Home Administrator (NHA), Director of Nursing (DON), and a Certified Nursing Assistant (CNA) confirmed that the facility's protocol required all motorized wheelchairs to be charged in the Beauty Shop. The CNA noted that R8 was the only resident with a motorized wheelchair, indicating a lack of adherence to the established procedure. The DON acknowledged the deficiency and initiated staff education to reinforce the correct charging protocol, emphasizing that any deviation from this procedure should be immediately corrected.
Inadequate Pain Management for Resident
Penalty
Summary
The facility staff failed to adequately assess and manage the pain of a resident, identified as R6, who was reviewed for pain management. R6 did not receive his scheduled pain patch, which led to ineffective pain management and caused him to miss two physical therapy sessions. The facility also did not assess the resident's pain goal or complete a comprehensive care plan that included his pain goal and non-pharmacological interventions. R6, who was admitted with diagnoses including chronic pain, reported not receiving his pain medication as prescribed, which hindered his participation in therapy. The facility's Medication Administration Record indicated multiple instances where R6's lidocaine patches were not administered due to unavailability, and no progress notes were written for these missed doses. R6 expressed that his pain level was consistently high, affecting his ability to engage in therapy, which he needed to do in order to return home. Interviews with facility staff, including LPNs and the Director of Nursing, revealed a lack of adherence to the facility's policies regarding medication availability and documentation. The staff acknowledged that missed medications should be documented as medication errors and communicated to the medical provider, but this was not consistently done. Additionally, the care plan for R6 lacked a specific pain goal and non-pharmacological interventions, which were necessary for effective pain management.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R6, by not ensuring the availability and administration of Lidocaine patches as prescribed. R6, who was admitted with conditions including chronic pain, did not receive the prescribed Lidocaine patches on multiple occasions due to the medication not being available. This resulted in medication errors on specific dates, as documented in the Medication Administration Record (MAR), where the medication was marked as unavailable. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that the process for handling unavailable medications was not consistently followed. Although there was a contingency stock accessible to licensed nurses, the medication was not obtained, and progress notes were not written for the missed doses. The staff acknowledged that a missed medication should be reported to the physician and documented as a medication error, but this protocol was not adhered to, leading to the deficiency.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were free from unnecessary medications, as evidenced by deficiencies found in the care of two residents. Resident 16, who was admitted with diagnoses including anxiety disorder, depression, and insomnia, was receiving psychotropic medications without a care plan for targeted behaviors or behavior tracking. The resident was administered a PRN anti-anxiety medication beyond the 14-day period allowed without a physician follow-up, contrary to the facility's protocol which requires a 14-day stop date and a physician's face-to-face visit before reordering. Interviews with the LPN and DON confirmed the lack of behavior tracking and the inappropriate administration of the medication. Resident 22, admitted with diagnoses of depression and unspecified dementia with psychotic disturbance, was receiving an antipsychotic medication without an Abnormal Involuntary Movement Scale (AIMS) assessment, which is required to monitor for side effects such as Tardive Dyskinesia. The facility's policy mandates AIMS assessments at admission, with new orders or changes in orders, and quarterly. Interviews with the LPN and DON revealed that the required AIMS assessment was not conducted for this resident, indicating a failure to adhere to the facility's monitoring protocols.
Failure to Offer Updated COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that their COVID-19 Vaccine policy and procedure were up-to-date and properly implemented for two residents, identified as R22 and R11. The facility's policy, dated December 5, 2024, mandates that upon admission, the immunization status of individuals should be verified, updated with the Primary Care Provider (PCP) as needed, and immunizations administered as ordered. However, the facility's current recommendations were outdated, referencing the 2023-2024 formula instead of the 2024-2025 COVID-19 vaccine guidelines. According to the CDC's Interim Clinical Considerations, individuals aged [AGE] and older are recommended to receive two doses of the 2024-2025 COVID-19 vaccine, yet R22 and R11 were neither offered nor documented to have received the vaccine for the 2024-2025 season. R22, who is over the age of [AGE] and has a medical history including essential hypertension, dementia, and a history of stroke, had documented COVID-19 vaccinations in 2021 but none for the 2024-2025 season. Similarly, R11, also over the age of [AGE], with chronic conditions such as heart failure, COPD, and chronic kidney disease, had documented vaccinations up to 2022 but not for the current season. The Director of Nursing/Infection Preventionist (DON/IP) confirmed during an interview that neither resident was offered the 2024-2025 COVID-19 vaccine, acknowledging that they should have been offered the vaccine according to the updated guidelines.
Failure in Antibiotic Stewardship Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program, which resulted in a resident receiving inappropriate antibiotic treatment. The resident, who had a history of diabetes mellitus type 2, chronic respiratory failure with hypercapnia, heart failure, and dementia, was diagnosed with a urinary tract infection (UTI) in the emergency department. The UTI was caused by Enterobacter cloacae complex and Methicillin Resistant Staphylococcus aureus (MRSA), a multi-drug resistant organism. Despite this, the facility did not obtain the resident's urinalysis culture and sensitivity (UA C/S) results from the hospital to ensure the resident was receiving the correct antibiotic. The resident was prescribed Cefdinir, which is not effective against MRSA, and the facility did not administer the medication until the following morning due to its unavailability in contingency. The facility did not follow up on the urine culture and sensitivity results, which were available three days later, and failed to recognize that Cefdinir was not indicated for MRSA. Consequently, the resident's condition worsened, leading to hospitalization for sepsis due to the UTI. The resident required intravenous antibiotics and fluids, and the hospital adjusted the antibiotic treatment based on the culture susceptibilities. The facility's failure to follow up on the culture and sensitivity results and notify the physician about the inappropriate antibiotic treatment contributed to the resident's hospitalization. The Director of Nursing and Registered Nurse acknowledged the lack of follow-up and identified it as a deficiency in the facility's antibiotic stewardship process. The previous Director of Nursing, who was also the Infection Preventionist, was no longer employed at the facility due to this oversight.
Failure to Notify Physician of Resident's Hypotension
Penalty
Summary
The facility failed to immediately consult with a physician when needing to alter treatment for a resident who experienced four instances of hypotension over a period of time. Despite the facility's policy requiring immediate physician notification for blood pressure deviations from baseline, the staff did not contact the on-call physician to report the resident's low blood pressure, which could have allowed for an alteration of treatment if deemed necessary by the physician. The facility's policy and the INTERACT II guidelines both indicate that a blood pressure less than 90 requires immediate physician notification, yet this protocol was not followed. The resident involved had a history of chronic conditions, including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, chronic kidney disease, Atrial fibrillation, and obstructive sleep apnea. The resident's vital signs on multiple occasions showed blood pressure readings below the threshold that necessitated physician notification, as per the discharge transfer orders and facility policy. However, there was no documentation or progress notes indicating that a physician was notified of these vital signs. Interviews with the Director of Nursing and a Registered Nurse confirmed that the discharge transfer orders should have been treated as physician orders and that a full RN assessment and physician notification should have occurred upon identifying the resident's hypotension.
Failure to Monitor Weight for Resident with CHF
Penalty
Summary
The facility failed to meet professional standards of quality for a resident with a history of Congestive Heart Failure (CHF) by not having a physician order for regular weight monitoring, which is crucial for managing CHF. The facility's policy on weighing individuals states that weights should be obtained and reviewed according to orders, including on admission, weekly for the first four weeks, and monthly thereafter. However, the resident in question was not weighed for months at a time, with recorded weights only on three occasions over a six-month period. This lack of regular weight monitoring is contrary to the recommendations of the American Heart Association, which advises daily weights for individuals with heart failure to detect early signs of fluid retention. The deficiency was further highlighted during an interview with the Director of Nursing (DON) and a Registered Nurse (RN), who acknowledged that discharge transfer orders, which included instructions to notify the physician of significant weight changes, should have been transcribed into the electronic medical record or reviewed by the facility physician. Despite the resident's medical history and the discharge transfer orders, there was no standard practice in place for weighing residents, and the facility relied solely on physician orders. The Nurse Practitioner (NP) involved in the resident's care did not respond to inquiries about their expectations for monitoring the resident's weight, leaving the deficiency unaddressed at the time of the survey.
Failure to Label Insulin Vial in Accordance with Professional Principles
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, as observed during the administration of insulin to a resident. The surveyor noted that a Medication Technician administered Humalog (Lispro) to a resident from a vial that did not have the resident's name indicated. The vial was observed to be pulled from contingency, and the Medication Technician confirmed that it was not labeled with the resident's name, assuming it belonged to the resident as they were the only one receiving Humalog from that cart. The resident involved had multiple diagnoses, including diabetes mellitus type 2, chronic respiratory failure with hypercapnia, heart failure, and dementia. The facility's policy on medication administration requires that medications be labeled and verified against the medication administration record (MAR) using the Five Rights principle. However, the lack of labeling on the Humalog vial was a deviation from this policy. The Licensed Practical Nurse and the Director of Nursing both acknowledged that medications pulled from contingency should be labeled immediately with the resident's name and room number, which was not done in this instance.
Deficiencies in Wound Care and Treatment Lead to Resident Harm
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, leading to significant health issues. One resident, who had diabetes mellitus type 2 and a history of amputations, experienced a change in condition with the development of a diabetic wound on the right second toe. The facility did not perform daily diabetic foot checks, assess or measure the wound, or update the resident's provider. This lack of care resulted in the wound becoming infected with multiple life-threatening multidrug-resistant organisms, leading to osteomyelitis and the eventual amputation of the toe. Another resident suffered a burn on the foot due to improper treatment with undiluted Tea Tree Oil. The facility failed to conduct weekly assessments as per professional standards, resulting in the wound becoming infected and requiring antibiotics. The resident's condition was further complicated by peripheral arterial disease, which increased the risk of complications and poor prognosis. The deficiencies in care for both residents were due to the facility's failure to adhere to professional standards of practice, including the lack of timely wound assessments, failure to notify providers of changes in condition, and incomplete administration of prescribed treatments. These actions and inactions led to immediate jeopardy for the residents, with one requiring hospitalization and surgery, and the other experiencing prolonged wound healing and hospitalization.
Removal Plan
- Skin sweep of entire facility completed
- Sweep of all active treatment orders completed for accuracy
- All residents with DM have daily foot checks added to TAR
- Education will be mandatory for all nurses and CNA including: DM foot care with completing daily diabetic foot checks; skin change observation expectations are that CNA report all skin changes immediately to the nurse; provider notification and change of conditions expectations are that nurses will report all diabetic foot ulcers, redness, purulence, drainage to physician; weekly wound assessments with measurements; and treatments completed as ordered
- DON or designee will ensure DM foot checks done daily, weekly and monthly bringing results to QAPI
- DON or designee will ensure weekly skin checks are completed daily, weekly and monthly bringing results to QAPI
- DON or designee will ensure weekly skin documentation completed during wound rounds; weekly and monthly bringing results to QAPI
- DON or designee will audit wound care treatments two residents weekly and monthly bringing results to QAPI
- Clinical Nurse Consultant will audit process of PCC documentation / 24 hour board follow up weekly and monthly to ensure changes of condition have needed follow up completed
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by interviews and record reviews. Two residents, R6 and R11, reported experiencing long wait times for their call lights to be answered, sometimes up to an hour or more. These delays were attributed to insufficient staffing, particularly during the PM shift, which left the staff overworked and unable to attend to residents promptly. The facility's staffing grid, used to determine staffing levels, was based on resident census rather than the acuity of the resident population, leading to inadequate staffing levels. Staff members, including CNAs and LPNs, expressed concerns about the impact of low staffing on their ability to complete tasks and provide necessary care. They reported frequent call-ins and a lack of accountability under previous management, which exacerbated staffing shortages. As a result, essential tasks such as showers, changing residents, and restorative care were not consistently completed, and residents were not always checked and changed as needed. The facility's scheduler, Scheduler K, confirmed that the staffing grid did not account for resident acuity and that previous administration directed her to follow this grid. The new Nursing Home Administrator acknowledged the issue and indicated plans to adjust scheduling to consider resident acuity. The Director of Nursing also noted staffing challenges during the transition from agency to in-house staff, which contributed to the staffing concerns.
Failure to Update Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct and document an up-to-date facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, which is required by nursing home participation requirements, was not updated annually or as needed. The existing Facility Wide Resource Assessment, dated December 2022, did not reflect the current resident population or the resources and education needed to appropriately care for them. During the survey, the Nursing Home Administrator (NHA) initially provided a PowerPoint presentation titled 'CMS minimum staffing mandate and facility assessment enhancements' instead of an actual assessment. Upon further inquiry, the Clinical Nurse Consultant (CNC) acknowledged the absence of a proper assessment and expressed embarrassment. The NHA, who was new to the facility and position, admitted that the PowerPoint was not a true assessment of the facility's resident population. Eventually, the outdated assessment from December 2022 was provided, and the NHA acknowledged the need for an accurate and up-to-date assessment.
Failure to Conduct Daily Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that four sampled residents received daily diabetic foot checks as required by professional standards of practice. The facility's policy, Standard Diabetes Mellitus Protocol, mandates daily foot checks for residents with diabetes to monitor potential complications. However, upon review, there was no documentation to support that these checks were completed for the residents in question. The residents involved had various medical conditions, including diabetes mellitus type 2, neuropathy, and other related health issues, which necessitated regular foot care to prevent complications. The surveyor's review of medical records and interviews with the Director of Nursing (DON) revealed a lack of evidence for the completion of daily diabetic foot checks for the residents. Despite the facility's policy and the DON's acknowledgment of the necessity for these checks, there was no documentation to demonstrate compliance. The absence of records for daily foot checks was confirmed for each resident, indicating a systemic failure in adhering to the established protocol for diabetic foot care.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving a Certified Nursing Assistant (CNA) and a resident, identified as R2. The facility's policy mandates that upon receiving an abuse allegation, a comprehensive investigation should be conducted, including interviews with involved parties and protection of the resident from the alleged perpetrator. However, the facility did not adhere to this policy. On 8/2/24, the facility became aware of an abuse allegation against a CNA, but the investigation was not thorough. R2, who is cognitively intact with a BIMS score of 13, reported that a CNA verbally abused her on 8/1/24. The facility preliminarily identified CNA C as the potential perpetrator based on R2's description, yet failed to obtain a statement from CNA C regarding the allegations. Despite the ongoing investigation, the facility allowed CNA C to return to work on 8/3/24, before the investigation was completed on 8/6/24. This decision was made without gathering sufficient information or conducting additional interviews that could have revealed further concerns. The facility's documentation showed inconsistencies regarding CNA C's presence in the facility on the dates in question. The Director of Nursing (DON) and Clinical Nurse Consultant (CNC) acknowledged the possibility of additional concerns arising during the investigation period. The facility's failure to protect residents and thoroughly investigate the allegations resulted in a deficiency in handling abuse allegations.
Deficiencies in Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with indwelling catheters, as evidenced by deficiencies in monitoring urine output and following current standards of practice for catheter changes. Three residents, identified as R1, R11, and R14, were affected by these deficiencies. R1 and R11 had physician orders for monthly catheter changes, which is not aligned with current CDC guidelines that recommend changes based on clinical indications. Additionally, urine output for R1 and R11 was not being monitored as required by facility policy. R1, who has a neurogenic bladder and a history of urinary tract infections, did not have his urine output documented, and his catheter care was not consistently performed as ordered. Similarly, R11, who is receiving palliative care and has moderate cognitive impairment, also did not have her urine output monitored, and she missed multiple catheter care treatments according to her physician's orders and facility policy. R14, with moderate cognitive impairment and a history of urinary tract infections, had active orders for two different sizes of Foley catheters, which could lead to confusion in care. Interviews with facility staff, including an LPN, a CNA, and the DON, revealed inconsistencies in the responsibility and documentation of urine output monitoring. The CNA reported that only one resident had orders for monitoring urine output, and despite notifying the nursing staff and DON, the necessary orders were not added to the electronic medical record. The DON confirmed that urine output should be monitored every shift and documented in the electronic medical record, but this was not being done for all residents with catheters.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents receiving psychotropic medications were free from unnecessary drugs, as evidenced by the lack of appropriate diagnoses or indications for the use of these medications. Resident 11 was prescribed Quetiapine for agitation/anxiety, which is not an appropriate indication for an antipsychotic. The Director of Nursing (DON) acknowledged that Resident 11 did not have an appropriate diagnosis for the use of Quetiapine. Similarly, Resident 12 was prescribed Quetiapine for dementing illness with associated behaviors, which is also not an appropriate indication for an antipsychotic, as confirmed by the DON. Resident 10 was receiving Citalopram and had been receiving Haldol, but the physician orders did not specify the diagnoses associated with these medications. The facility lacked signed written consents indicating the associated diagnoses for Resident 10's medications. The DON admitted that the diagnoses should have been included in the physician orders and that they are typically added within 48 hours, but this was not done in this case. The absence of appropriate diagnoses and documentation for the use of psychotropic medications led to the deficiency identified by the surveyors.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three of the seven sampled residents. Resident R9 did not receive a scheduled dose of Apixaban, a blood thinner, due to the medication being unavailable, and the physician was not notified of this error. The Director of Nursing (DON) confirmed that the medication was not given and acknowledged that it should have been administered, with the physician being contacted in such cases. Resident R13 missed two doses of Insulin Glargine, a long-acting insulin, on separate occasions. The medication administration record indicated that the doses were held, but there were no documented parameters or physician orders to justify holding the insulin. The Licensed Practical Nurse (LPN) involved could not find any orders for holding the insulin and admitted that the physician should have been contacted for guidance. The DON also confirmed the absence of hold orders and expected the nurse to seek physician advice before making such decisions. Resident R1 experienced multiple missed doses of insulin and anticoagulant medication without valid physician orders or notification. The resident's medical record lacked signed hold orders for Enoxaparin, an anticoagulant, and the DON admitted that missed doses were considered medication errors. The DON also acknowledged that physician orders were not signed since June, and there was an assumption that all orders were electronically signed, which was not the case. The surveyor confirmed that the physician should have been contacted for missed medications or errors.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the facility's schedules and an interview with the Assistant Director of Nursing (ADON C). On Saturday, July 6, 2024, and Sunday, July 7, 2024, the facility did not have an RN present for the required 8 consecutive hours. The ADON confirmed that there is not always an RN in the facility on weekends for the mandated duration. This oversight has the potential to affect all 32 residents residing within the facility.
Failure to Conduct Care Conferences Due to Lack of Social Worker
Penalty
Summary
The facility failed to provide necessary social service assistance for four residents, resulting in a lack of care conference meetings. The absence of a social worker for several months contributed to this deficiency, as the facility was unable to conduct care conferences consistently. Residents R2, R5, R3, and R4 did not have their required care conference meetings, which are essential for ensuring person-centered care and prioritizing resident goals. Specifically, R2 did not have any care conference meetings in 2024, and R5 had not had a care conference since admission. R3 and R4 also missed their quarterly care conferences, with their last meetings occurring in early 2024. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lapse in care conference meetings, attributing it to the absence of a social worker. The facility's policy on Individual Advance Care Planning emphasizes the importance of discussing and verifying advance care planning upon admission, re-admission, change in condition, and during care conferences. However, due to the lack of a social worker, these meetings were not held consistently, impacting the facility's ability to support residents in achieving their care goals.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for two residents, R5 and R4, as observed by the surveyor. R5 was found with medication at her bedside without a completed self-administration assessment. Despite R5's indication that she is dependable and the medication being a vitamin, the Director of Nursing (DON) confirmed that R5 did not have an assessment and was not able to safely self-administer medications. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents to self-administer medications, which was not followed in R5's case. Similarly, R4 reported that staff generally leave medications on her bedside table, which she takes within an hour. R4 did not recall any assessment being performed to determine her ability to self-administer medications safely. The surveyor's review of R4's care plan and records confirmed the absence of any documentation supporting her ability to self-administer medications. The DON acknowledged that R4 did not have a self-administration assessment and that medications should not be left at her bedside, indicating a failure to adhere to the facility's policy.
Failure to Investigate Alleged Verbal Abuse Between Residents
Penalty
Summary
The facility failed to ensure a thorough investigation and appropriate response to an alleged incident of verbal abuse between two residents, R4 and R6. On June 23, 2024, R4, who is cognitively intact with a BIMS score of 13, was reported to have yelled at R6 during a meal, telling him to 'knock it off and shut up' due to R6's medical condition causing him to aspirate and cough. This behavior was noted in R4's progress behavior note and was a repeated occurrence, as indicated by the psychiatric follow-up note on July 10, 2024, which documented R4's irritability and use of foul language. Despite the incident being reported by a CNA to an LPN, and the LPN acknowledging the potential for the incident to be considered abuse, no formal investigation was conducted. The LPN reported the situation to an agency nurse, but no further action was taken. The Director of Nursing (DON) was aware of the incident but did not pursue further investigation, believing the situation had resolved itself by separating the residents. The DON later acknowledged that further intervention would have been warranted had the repeated nature of the incidents been known. The facility's policy on abuse, neglect, and mistreatment requires thorough investigation and intervention in such cases, but this was not adhered to. The lack of investigation and follow-up on the repeated verbal altercations between R4 and R6 represents a failure to protect residents from potential abuse, as required by the facility's own policies and procedures.
Failure to Develop Safe Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement a discharge planning process for a resident, identified as R2, who had expressed a desire to return home. Despite being aware of R2's intention to discharge home, the facility did not engage in discussions with R2 to create a safe discharge plan. R2 was admitted with multiple diagnoses, including alcohol polyneuropathy, hypertension, and depression, and had a care plan that initially indicated a wish to remain in the facility for a long stay. However, the care plan lacked updates and new interventions since 2022 to ensure a safe discharge, and it was unclear what R2's discharge goals were. On the evening of R2's discharge, staff, including an LPN and CNAs, were aware of R2's plan to return home and had observed R2 packing to leave. The LPN attempted to educate R2 on the importance of a safe discharge and the need for medications, but R2 insisted on leaving without them. The facility had been without a social worker for several months, and the Director of Nursing acknowledged that R2's discharge care plan should have been current and reflective of R2's desires. The lack of a robust discussion and planning led to R2 leaving without appropriate community supports, notifications, orders, and medications in place, resulting in an unsafe discharge.
Failure to Provide Necessary Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living, received the necessary services to maintain good personal hygiene. The resident, who was admitted with conditions such as morbid obesity, anemia, depression, urinary incontinence, muscle weakness, and difficulty in walking, did not receive a shower between July 5 and July 17, 2024. The resident's care plan indicated a need for assistance with personal care, but the bathing/showering section did not specify the amount of assistance required. During an interview, the resident reported not having had a shower in two weeks and expressed frustration that staff did not respond to her requests. The surveyor's investigation revealed that the facility lacked documentation of the resident's showers during the specified period. Interviews with staff, including a CNA and the DON, indicated that showers were sometimes missed due to staffing issues, and there was no record of the resident's shower schedule or any refusals. The facility's procedure for documenting and communicating missed showers was not followed, as evidenced by the absence of shower sheets and lack of information on the 24-hour report sheet. This deficiency highlights a failure in the facility's processes to ensure residents receive necessary personal hygiene care.
Failure to Implement Isolation Precautions for C. diff Infection
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the mishandling of a resident's admission with a Clostridium difficile (C. diff) infection. Upon admission, the resident, who had a diagnosis of enterocolitis due to C. diff, was not placed on isolation precautions as required by CDC guidelines. The facility's policy on outbreak and isolation procedures, which aligns with CDC guidelines, mandates immediate isolation for suspected or confirmed C. diff infections. However, this protocol was not followed, resulting in a lapse in infection control measures. The deficiency was further highlighted during interviews with facility staff. RN D, who began the admission process for the resident, acknowledged that isolation precautions were not implemented due to an incomplete admission process during a shift change. It was only after RN D returned from a weekend off that the resident was placed on isolation, following a review of the resident's medication and hospital notes indicating a C. diff diagnosis. The Director of Nursing (DON B) confirmed that the resident was not put on contact precautions until several days after admission, despite the presence of a C. diff diagnosis, which should have prompted immediate isolation measures.
Failure to Notify Physician of AMA Discharge
Penalty
Summary
The facility failed to notify the physician when a resident left the facility against medical advice (AMA). According to the facility's policy on discharges against medical advice, staff are required to notify the physician, Adult Protective Services, and the activated Power of Attorney for Health Care agent or Guardian, as indicated. The resident was admitted to the facility and discharged AMA with a family member. A review of the resident's progress notes from the time of admission to discharge showed no evidence that the physician was notified of the AMA discharge. Interviews with the Executive Director and an LPN confirmed that the physician was not notified, despite the requirement to do so.
Failure to Timely Report Misappropriation Allegation
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of resident property for one of the sampled residents. According to the facility's policy, any allegations involving abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately, or within 24 hours if the events do not involve abuse or result in serious bodily injury. In this case, a resident with a medical history of a right femur fracture, chronic pain, and opioid use reported to a licensed practical nurse that a family member was taking their money to buy drugs. This allegation was made on May 10, 2024, but the Executive Director was not notified until May 12, 2024, and the local police department and adult protective services were informed on May 13, 2024. The facility further delayed notifying the state agency, which was not done until May 21, 2024. During interviews, the Executive Director acknowledged being aware of the allegation on May 11, 2024, and admitted to reporting it to the state agency on May 13, 2024, outside the required reporting period. The Executive Director also mentioned that she believed she had submitted all necessary documentation but realized it was not done timely. This series of actions and inactions led to the deficiency in reporting the misappropriation allegation as per the facility's policy and federal and state laws.
Failure to Arrange Home Health Services for Discharged Resident
Penalty
Summary
The facility failed to arrange home health services for a resident who was discharged home. The resident, who had a medical history including orthopedic aftercare following surgical amputation, acute right ankle and foot osteomyelitis, and peripheral vascular disease, was admitted to the facility and expressed a desire to return home after completing therapy. The care plan directed staff to arrange necessary community resources to support the resident's independence post-discharge. However, upon discharge, the resident was not contacted or seen by the home health services that were supposed to be in place. The Assistant Director of Nursing (ADON) acknowledged that the home health referrals were not made until the resident called the facility after discharge, indicating a lapse in the discharge process. The Executive Director (ED) and the Director of Nursing both stated that the nursing team was responsible for ensuring discharge referrals were sent to the home health agency, but it was unclear if this was done for the resident. This oversight resulted in the resident being advised to seek emergency department care for wound care needs until home health services could be arranged.
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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