Stevens Point Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Stevens Point, Wisconsin.
- Location
- 1800 Sherman Ave, Stevens Point, Wisconsin 54481
- CMS Provider Number
- 525353
- Inspections on file
- 29
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Stevens Point Health Services during CMS and state inspections, most recent first.
The facility did not notify the State Long-Term Care Ombudsman of multiple resident transfers and discharges as required by policy. Several residents with varying medical conditions and cognitive statuses were either transferred to the hospital or discharged home, but the Ombudsman was not informed in any of these cases.
Two residents, one with impaired cognition and another who was cognitively intact, were prescribed multiple medications, including psychotropic and anticonvulsant drugs, without the facility obtaining the required written consents. In one case, only verbal consent was documented from a POAHC, and in the other, no medication consents were obtained, as confirmed by the NHA.
A resident with multiple medical conditions was prescribed sertraline and trazodone, but staff failed to document monitoring for the efficacy or adverse consequences of these psychotropic medications as required by facility policy. The absence of such monitoring was confirmed through record review and staff interview, with the DON acknowledging the oversight.
A facility did not ensure a timely and complete background check for an agency RN, allowing the nurse to begin work before a properly dated Background Information Disclosure (BID) form was on file. The missing date on the BID form was not identified or addressed by the Business Office Manager, and the agency only provided a correctly dated form after the RN had already started.
A resident with multiple complex medical conditions was readmitted to the facility twice after hospitalizations for sepsis and urosepsis, but the care plan was not revised to address these significant changes in condition. Previous interventions for monitoring infection and catheter care had been resolved and were not reinstated, leaving the care plan outdated and not reflective of the resident's current needs.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
A resident with diabetes and heart failure was given 81 mg EC aspirin and two sprays of fluticasone propionate nasal spray in each nostril, contrary to physician orders for aspirin in capsule form and only one spray per nostril. The RN administering the medications was unsure about the transcription of the aspirin order, and the DON confirmed both the transcription and administration errors.
A resident with multiple chronic conditions and MRSA colonization was care planned for enhanced barrier precautions (EBP), requiring staff to use gowns and gloves during high-contact care. A CNA was observed providing peri-care without a gown, despite posted EBP signage and care plan instructions. The CNA admitted to not following EBP protocol, and the facility lacked a specific EBP policy when requested.
A medication cart was found unlocked and unattended near the nurses' station, with two residents nearby—one walking past with a walker and another sitting in the common area. Facility policy requires medication carts to be locked when not attended by authorized staff. The RN involved acknowledged leaving the cart unlocked, and the DON confirmed that carts should always be secured.
Surveyors found that staff did not consistently follow individualized meal tickets or accommodate food preferences for multiple residents, resulting in missed or incorrect meal components such as desserts, beverages, and side items. Interviews with staff and management confirmed that meal tickets were not always followed, and supply issues contributed to some omissions. Residents with specific dietary needs, including those with cardiac diets and dysphagia, did not receive meals as ordered.
A resident with diabetes, a recent stroke, and moderate cognitive impairment was transferred using a sit-to-stand lift by two CNAs while wearing non-gripper socks, contrary to facility policy requiring non-skid footwear during transfers. The DON confirmed that proper footwear should have been used to ensure safety.
A resident with severe cognitive impairment and swallowing difficulties was not provided with lidded cups and a divided plate during a meal, despite these items being specified on the meal ticket and required by facility policy. Staff and management confirmed the resident should have received the adaptive equipment.
Staff did not use required PPE, including gowns and gloves, during high-contact care activities for a resident on Enhanced Barrier Precautions (EBP), despite clear policy and signage. The DON confirmed that EBP should have been followed during these cares.
A resident and their family reported concerns of neglect and inappropriate staff behavior, including delayed care and improper transfer methods. Despite these reports, staff did not recognize or report the allegation to the State Agency as required, and the administrator was unaware of the incident until the survey.
A resident with multiple health conditions reported not receiving care for an extended period, resulting in incontinence, and relayed this to a medication technician. The concern was passed to a social worker, but no investigation or documentation followed. Additionally, the resident's family reported staff making inappropriate comments and concerns about transfer equipment, but these were not fully investigated or documented.
A resident admitted with a left heel pressure injury did not receive accurate and comprehensive wound assessments as required by facility policy. Documentation showed inconsistencies in wound staging and tissue description, and the facility lacked wound care certified nurses, relying on an external provider while the resident was followed by an outside wound clinic. These actions resulted in a failure to provide necessary care and services to promote healing and prevent further pressure injury development.
Staff did not adhere to infection control protocols during medication administration, including failing to perform hand hygiene and not wearing required PPE such as gowns and gloves when caring for residents on contact precautions. Both a medication technician and an LPN were observed not following these procedures, and acknowledged their lapses during interviews. Facility policy and posted signage required these infection control measures, but they were not implemented as observed.
A resident with dementia experienced a decline in health, including weight loss and reduced transfer ability, without the facility notifying the court-appointed Guardian. Despite significant changes, the care plan was not updated, and the Guardian was not informed, leading to dissatisfaction when the resident was found unresponsive and transferred to a hospital. The facility acknowledged the communication failure and the need for a therapy consultation.
A resident with dementia experienced significant weight loss due to the facility's failure to consistently monitor and document meal intake. Despite the Registered Dietitian's involvement, 18.36% of meals were undocumented, and the resident's cognitive decline led to increased meal refusals. The Director of Nursing acknowledged the oversight in documentation and review processes.
Two residents in the facility did not receive necessary care to prevent and heal pressure injuries. One resident developed an unstageable deep tissue injury on the heel due to splints not being removed for skin checks, and a sacral pressure injury was not treated promptly. Another resident's heel pressure injury was not assessed or treated in a timely manner, leading to infection. The facility failed to follow its policy requiring weekly assessments, resulting in inadequate documentation and care.
The facility failed to ensure proper PPE usage for two residents on enhanced barrier precautions (EBP). A CNA assisted a resident with urinary concerns without wearing a gown, despite EBP signage and policy requirements. Another CNA provided care to a resident with wounds and colonized bacteria without the necessary gown. Both residents, who were not cognitively impaired, confirmed the inconsistency in PPE usage.
A resident with COPD and diabetes, requiring staff assistance for bathing, did not receive scheduled showers on multiple occasions. The resident, who had moderate cognitive impairment, was scheduled for weekly showers but missed several due to refusals and lack of documentation. The DON confirmed the resident often refused care and that missing documentation indicated missed showers.
A resident with COPD, lung cancer, and bone cancer did not receive timely and accurate administration of oxycodone as per physician orders. The facility's Medication Administration Audit Report showed multiple instances of late administration and improper concurrent dosing of scheduled and PRN oxycodone. The DON confirmed these discrepancies, indicating a failure to adhere to the facility's medication administration policy.
The facility did not designate a qualified person to serve as the food and nutrition services director. The Dietary Manager had not completed an approved certification course and was only enrolled in a ServSafe course. The DM had previous experience in maintenance and as a cook in an assisted living facility. The facility had a contracted dietician who was onsite every other week.
The facility failed to ensure food was stored and prepared safely, with staff not following proper hand hygiene, cleanliness, and equipment storage protocols. Additionally, unit refrigerator and freezer temperature logs were not maintained, and open items were not dated.
The facility did not ensure that the designated Infection Preventionist (IP) completed the required training and was employed at least part-time. The DONM, who was overseeing the IP role, did not work scheduled hours and was more of a consultant. The ADON, who was being mentored, had not completed all required training modules. This had the potential to affect all 42 residents.
A resident with a right femur fracture and moderately impaired cognition experienced significant pain but did not receive timely pain relief due to delays in obtaining morphine from the emergency kit. The facility's reliance on a PIXUS machine and issues with the pharmacy contributed to the delay, resulting in prolonged suffering for the resident.
The facility failed to ensure the privacy of a resident during personal care. A surveyor observed that the window blind in the resident's door was open, allowing an unobstructed view of the resident's nude body from the nurses' station. Staff interviews confirmed that the blind should have been closed to ensure privacy.
The facility failed to provide necessary respiratory care for two residents using oxygen therapy. Both residents lacked physician's orders and care plans for oxygen use, and their oxygen tubing was not properly managed. The Director of Nursing confirmed these deficiencies during the survey.
A resident received COVID-19 and influenza vaccines despite their legal guardian's signed declination. The Director of Nursing confirmed the error, noting that staff failed to review the declination sheets properly.
The facility failed to maintain an effective infection control program, resulting in staff not wearing required PPE, improper hand hygiene, and failure to disinfect equipment during care for two residents. These lapses were confirmed by the DON and involved a CNA and an RN not following established protocols.
The facility failed to ensure that three residents were offered the PCV20 vaccine as per CDC guidelines, despite having received previous pneumococcal vaccinations. The Director of Nursing confirmed that the residents should have been offered the vaccine and that the documentation should have been included in their medical records.
The facility failed to ensure adequate fall prevention for three residents, including not updating care plans after falls, not addressing trip hazards, and not securing smoking materials as required.
The facility did not ensure the QAPI committee met at least quarterly and failed to provide verification of attendance for required members, impacting all 42 residents. Missing and unsigned sign-in sheets were found, and interviews confirmed the lack of proper documentation.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of transfers or discharges for four residents, as required by policy and regulation. Specifically, one resident with multiple medical conditions and intact cognition was transferred to the hospital for evaluation, but the Ombudsman was not notified. Another resident with moderately impaired cognition and an activated Power of Attorney for Healthcare was discharged home, yet the required notification was not made. A third resident, who had intact cognition and multiple chronic conditions, was transferred to the hospital for a change in condition and later returned, but again, no notification was sent. The fourth resident, also with intact cognition and significant medical diagnoses, was transferred to the hospital on three separate occasions for serious health issues, including septic shock and urosepsis, without Ombudsman notification each time. The facility's policy mandates that the Social Services Director or designee must notify the Ombudsman of non-emergency transfers or discharges at least 30 days in advance, and for emergency transfers, provide notice via a monthly list. However, record review and staff interviews revealed that the facility did not report any transfers or discharges to the Ombudsman during the period in question. This deficiency was confirmed when the Nursing Home Administrator acknowledged the lack of reporting and provided documentation showing that no notifications had been made.
Failure to Obtain Written Medication Consents for Two Residents
Penalty
Summary
The facility failed to ensure that two residents, both with significant medical and cognitive conditions, or their legal representatives, were fully informed and provided written consent for prescribed medications, including psychotropic and anticonvulsant drugs. For one resident with moderately impaired cognition and an activated Power of Attorney for Healthcare (POAHC), verbal consent was obtained for medications such as divalproex sodium (Depakote), buspirone, and clindamycin, but there was no documentation of written consent signed by the POAHC. This resident had diagnoses including dementia, stroke, diabetes, seizures, and depression, and was unable to make healthcare decisions independently. Another resident, who was cognitively intact and made their own healthcare decisions, was prescribed multiple medications including quetiapine, hydroxyzine, Ambien, Lyrica, Lexapro, and oxcarbazepine for conditions such as bipolar disorder, depression, anxiety, insomnia, and neuropathic pain. The facility did not obtain any medication consents for these psychotropic medications. The Nursing Home Administrator confirmed that signed medication consents should have been obtained for both residents.
Failure to Monitor Psychotropic Medication Efficacy and Adverse Consequences
Penalty
Summary
A deficiency occurred when the facility failed to monitor for adverse consequences or the effectiveness of psychotropic medications prescribed to a resident. The resident, who had diagnoses including urinary tract infection, chronic respiratory failure, COPD, encephalopathy, anxiety, and insomnia, was prescribed sertraline for anxiety and trazodone for sleep. Upon review, the resident's medical record did not contain documentation of monitoring for the efficacy or adverse consequences of either medication, such as sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremors, agitation, headache, skin rash, photosensitivity, excess weight gain, anxiousness, or sleeplessness. The facility's policy required that each resident's drug regimen be reviewed and monitored for unnecessary drugs, efficacy, and adverse consequences, especially for psychotropic medications. Despite this, there was no evidence in the resident's Medication Administration Record or Treatment Administration Record that such monitoring was performed for the prescribed antidepressants. The deficiency was confirmed through staff interview and record review, with the Director of Nursing acknowledging that monitoring should have been completed.
Failure to Complete Timely Background Check for Agency RN
Penalty
Summary
The facility failed to implement its policies and procedures to prohibit and prevent abuse by not ensuring a thorough and timely caregiver background check for one agency registered nurse. Specifically, the Background Information Disclosure (BID) form for the agency RN was not dated, and the nurse began working at the facility before a properly completed BID form was on file. The Business Office Manager did not notice the missing date on the BID form and did not follow up with the agency prior to the nurse's start date. The agency later provided a BID form with an effective date after the nurse had already started working.
Failure to Revise Care Plan After Hospital Readmissions for Sepsis/Urosepsis
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was revised in a timely manner for one resident following two separate hospital readmissions for sepsis and urosepsis. The resident, who had multiple diagnoses including urosepsis, bullous pemphigoid, COPD, various malignancies, UTIs, schizophrenia, and anxiety, was readmitted to the facility after hospitalizations for sepsis/urosepsis related to urinary tract infections. Despite these significant changes in the resident's condition, the care plan was not updated to reflect the new diagnoses or to include appropriate monitoring and interventions for infection. Record review and staff interviews revealed that the care plan previously included interventions for monitoring signs and symptoms of UTI, but these interventions had been resolved prior to the resident's hospitalizations and were not reinstated upon readmission. The care plan also referenced a catheter, but all related interventions had been resolved months before the most recent hospitalizations. As a result, the care plan did not address the resident's current needs following the episodes of sepsis and urosepsis.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Medication Order Transcription and Administration Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes and heart failure was administered medications that did not match the physician's orders. The resident, who was cognitively intact according to a recent assessment, was observed receiving 81 mg of enteric coated (EC) aspirin and two sprays of fluticasone propionate nasal spray in each nostril. However, the physician's orders specified aspirin 81 mg in capsule form (which was incorrectly transcribed from the hospital discharge summary that indicated EC tablet) and only one spray of fluticasone propionate in each nostril. The registered nurse administering the medications was unsure why the aspirin order was transcribed as a capsule and acknowledged that the facility did not have aspirin in capsule form. Upon review, it was confirmed that the order was incorrectly transcribed and the medication was not administered as ordered. Additionally, the nurse confirmed that the resident received double the prescribed dose of fluticasone propionate. The Director of Nursing verified these discrepancies and confirmed that the medications were not administered according to the physician's orders.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to maintain an infection prevention and control program as required for a resident on enhanced barrier precautions (EBP). The resident, who had multiple diagnoses including type 2 diabetes, chronic ulcers, MRSA colonization, and chronic respiratory failure, was care planned for EBP due to colonization with a multidrug-resistant organism (MDRO). The care plan and Kardex specified that staff should use gowns and gloves during high-contact care activities, such as peri-care and toileting, to prevent the transmission of infection. On the day of the survey, a certified nursing assistant (CNA) was observed providing peri-care to the resident without wearing a gown, despite signage indicating EBP and the care plan's requirements. The CNA acknowledged not donning a gown at the start of care and only halted care upon noticing the surveyor. Interviews with the infection preventionist confirmed that staff should follow the resident's precautions and use appropriate personal protective equipment (PPE) during high-contact care. Additionally, the facility did not have a specific EBP policy available when requested, providing only a general transmission-based precautions policy instead.
Unattended and Unlocked Medication Cart Observed
Penalty
Summary
A medication cart was observed unlocked and unattended on the second floor near the nurses' station, with two residents present in the vicinity. One resident walked by the cart using a walker, while another was seated in the common area watching television. The facility's policy requires that medication carts remain locked when not in use or when not attended by authorized personnel, such as licensed nurses or medication aides. The incident occurred when a registered nurse was pulled away from the medication cart and left it unlocked and unattended. Upon interview, the nurse acknowledged that the cart should not have been left in this state. The Director of Nursing also confirmed that medication carts are expected to be locked whenever nurses are not present.
Failure to Follow Individualized Meal Tickets and Food Preferences
Penalty
Summary
Surveyors identified that the facility failed to ensure that food preferences and individualized meal tickets were consistently accommodated for ten out of sixteen sampled residents. Observations, interviews, and record reviews revealed that staff did not follow specific dietary orders and preferences as indicated on residents' meal tickets. For example, one resident on a cardiac diet received a full-size brownie and a white roll instead of the specified half brownie and wheat roll, and another resident with dysphagia did not receive margarine, cabbage, or a frosted brownie as listed on their meal ticket. Additionally, several residents did not receive the beverages indicated on their meal tickets, such as milk, coffee, or juice, during lunch service. Staff interviews confirmed that beverages and other meal components were not always provided as required by the individualized meal tickets. Some staff indicated that residents could have whatever beverages they wanted unless on a fluid restriction, while others acknowledged that the meal tickets should be followed. The Director of Nursing and Dietary Manager both confirmed that staff are expected to follow the meal tickets and provide the items listed, including correct portion sizes and substitutions for allergies or preferences. The Dietary Manager also reported issues with food supply, such as the unavailability of margarine and the substitution of cucumber salad for coleslaw due to a delayed food delivery. Despite these supply issues, the expectation remained that meal tickets should accurately reflect what residents receive and that staff should follow them as written. The failure to provide meals and beverages according to individualized meal tickets resulted in residents not receiving their prescribed diets, preferences, or required nutritional items during meal service.
Failure to Ensure Proper Footwear During Mechanical Lift Transfer
Penalty
Summary
Staff failed to ensure that a resident with diabetes and a history of stroke wore proper footwear during a mechanical lift transfer. The resident, who had moderate cognitive impairment and was at risk for foot injury and falls, was observed being transferred with a sit-to-stand lift by two CNAs while wearing non-gripper socks. After the transfer, staff assisted the resident in putting on shoes and wheelchair pedals. Facility policy required the use of appropriate techniques and devices to ensure resident safety during transfers, including the use of non-skid footwear as outlined in both the facility's Safe Lifting and Movement of Residents policy and external nursing assistant guidelines. The DON confirmed that the resident should have worn shoes or gripper socks during the transfer, in accordance with these policies.
Failure to Provide Adaptive Eating Equipment as Ordered
Penalty
Summary
A deficiency occurred when staff failed to provide adaptive eating equipment as required for one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, cerebral ischemia, and dysphagia. The resident's meal ticket specified the need for cups with lids and a divided plate, in accordance with the facility's Assistive Devices policy and the resident's individualized plan of care. During a lunch observation, the resident was not given the specified adaptive equipment. Interviews with the Director of Nursing and the Dietary Manager confirmed that the resident should have received these items, and that procedures were in place for staff to obtain them if not immediately available.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact care activities for a resident with multiple medical conditions, including a prosthetic heart valve, colostomy, stroke, type 2 diabetes, and a history of infectious diseases. The resident's care plan included an intervention for EBP, and signage on the resident's door indicated the need for these precautions. Despite this, during an observed transfer using a sit-to-stand lift, two CNAs did not don the required personal protective equipment (PPE), such as gowns and gloves, while dressing and transferring the resident. Following the transfer, one CNA acknowledged that both staff members should have worn PPE in accordance with EBP requirements. The DON later confirmed that staff are expected to use gowns and gloves for high-contact care with residents on EBP. The deficiency was identified through observation, staff interviews, and record review, demonstrating a failure to implement the infection prevention and control program as outlined in facility policy.
Failure to Timely Report Alleged Abuse/Neglect to State Agency
Penalty
Summary
An allegation of abuse/neglect involving a resident was not reported to the State Agency (SA) in a timely manner as required by the facility's policy. The resident, who was cognitively intact with a BIMS score of 14 and had diagnoses including obesity, muscle weakness, anxiety, and depression, reported to a Medication Technician (MT) that staff failed to provide care over a weekend, resulting in the resident being left incontinent for an extended period. The resident's family member also reported concerns, including inappropriate staff comments and improper use of transfer equipment. Despite these reports, the facility staff did not follow the policy for reporting alleged violations. The MT relayed the concern to the Social Worker (SW), but the SW did not recognize or act on the abuse/neglect allegation, nor did the SW report it to the SA. The Nursing Home Administrator was unaware of the incident until informed by the surveyor, confirming that the required reporting did not occur.
Failure to Investigate Alleged Abuse/Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse/neglect involving one resident. The resident, who was cognitively intact and had diagnoses including obesity, muscle weakness, anxiety, and depression, reported that staff did not provide care over a weekend, resulting in the resident being left incontinent for an extended period. The resident informed a medication technician about the incident, who then relayed the concern to the social worker. However, the social worker did not inquire further about the incident, did not document the conversation, and did not initiate an investigation into the allegation. Additionally, the resident's family member reported concerns about inappropriate staff comments and the use of a mechanical lift for transfers. While the social worker addressed the transfer equipment issue, the comment made by staff was not investigated or documented. The nursing home administrator was unaware of the allegations and confirmed that a thorough investigation should have occurred, as required by the facility's abuse, neglect, and exploitation policy.
Failure to Accurately Assess and Document Pressure Injury Care
Penalty
Summary
The facility failed to provide necessary care and services to promote healing and prevent the development of pressure injuries for a resident admitted with a pressure injury (PI) on the left heel. The facility did not complete accurate and comprehensive assessments of the resident's left heel PI as required by their own policy, which mandates weekly wound assessments and proper documentation of wound characteristics. Medical records showed inconsistencies in the assessment of the wound, including discrepancies in the type of tissue present and changes in the staging of the PI without clear documentation. The resident's PI progressed from a stage 1 to an unstageable wound, with incomplete information regarding the wound's tissue composition. The resident had multiple diagnoses, including diabetes mellitus, chronic kidney disease, and dementia, and was admitted with a left heel PI. The facility lacked wound care certified nurses and relied on an external wound care provider for weekly rounds, but the resident was followed by an outside wound clinic instead. The facility's documentation and assessment practices did not align with their policy or with best practices for pressure injury management, as evidenced by incomplete and inaccurate wound assessments during the resident's stay.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during medication administration for three residents. Specifically, a medication technician and an LPN did not perform appropriate hand hygiene before preparing medications, before entering residents' rooms, after administering medications, or after exiting the rooms. In addition, both staff members did not don required personal protective equipment (PPE), such as gowns, when providing care to residents on contact precautions. The facility's policies and posted signage required hand hygiene and the use of gloves and gowns for all interactions involving residents on contact precautions, but these procedures were not followed. During direct observation, the medication technician did not perform hand hygiene at any point during medication preparation or administration for two residents, including one on contact precautions, and was unaware of the need to wear a gown. The LPN also failed to perform hand hygiene after removing gloves and handling medication equipment, and did not wear a gown when administering insulin to a resident on contact precautions. Both staff members acknowledged their lapses in hand hygiene and PPE use during interviews, and the DON confirmed the facility's expectations for these practices.
Failure to Notify Guardian of Resident's Decline
Penalty
Summary
The facility failed to notify a resident's court-appointed Guardian of significant changes in the resident's condition, which is a violation of their Change in Condition of the Resident policy. The resident, who had unspecified dementia, experienced a decline in transfer ability and eating habits over several months. Despite these changes, the facility did not communicate with the Guardian, who was responsible for the resident's healthcare decisions. The resident was eventually found unresponsive and transferred to a hospital, where the Guardian expressed dissatisfaction with the lack of communication. The resident's medical records showed a significant weight loss over a few months, indicating a decline in health. Staff interviews revealed that the resident's ability to communicate and eat had deteriorated, and the resident required increased assistance for transfers. However, these changes were not reflected in the care plan, and the staff failed to update the Guardian or the resident's primary care provider about the resident's declining condition. The Director of Nursing and other facility leaders acknowledged that the staff should have communicated the resident's decline to the Guardian and considered a therapy consultation. The facility's interdisciplinary team was supposed to review at-risk resident records weekly, but the necessary updates and notifications were not made. The resident was eventually discharged from the hospital with hospice services and passed away shortly after.
Failure to Monitor and Document Nutritional Intake
Penalty
Summary
The facility failed to consistently monitor and document the nutritional intake of a resident, leading to a significant weight loss. The resident, who had been diagnosed with unspecified dementia and had a court-appointed guardian for healthcare decisions, experienced a decline in cognitive function during their stay. The resident's weight decreased from 207.6 pounds to 158 pounds over a period of several months, with the most severe loss occurring in January. Despite the Registered Dietitian being informed and ordering nutritional supplements, the resident's meal intake was not consistently documented, with 18.36% of meals missing documentation. Interviews with staff revealed that the resident, initially having a good appetite, began refusing meals and had difficulty communicating with staff. The Director of Nursing confirmed that meal intake should be documented for every meal and that the Interdisciplinary Team reviews at-risk resident records weekly. However, the missing documentation was not identified or addressed during these reviews, contributing to the deficiency in monitoring the resident's nutritional status effectively.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and heal pressure injuries for two residents. One resident, admitted with fractures and bilateral splints, developed an unstageable deep tissue injury on the right heel due to the splints not being removed for skin checks. Additionally, a pressure injury on the sacrum was not treated until three days after admission, and an air mattress was not ordered until ten days post-admission. The facility's Director of Nursing confirmed that the splints were not removed for skin checks, and there was no policy addressing skin care with medical devices. Another resident was admitted with a pressure injury on the left heel, but a wound assessment and treatment order were delayed until two weeks after admission. The facility failed to complete weekly wound assessments and did not notify the wound clinic when the wound showed signs of infection. The resident's medical record lacked documentation of the pressure injury assessments for several weeks, and the wound clinic noted a copious amount of purulent exudate, indicating an infection that the facility did not report. The facility's policy required weekly assessments for pressure injuries, which were not followed, leading to a lack of documentation and appropriate wound care. Interviews with the Director of Nursing and other staff confirmed the absence of weekly charting and documentation, and the facility's failure to adhere to its wound care policy and standards of practice.
Inadequate PPE Usage for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices related to the use of personal protective equipment (PPE) for two residents on enhanced barrier precautions (EBP). Resident 2 was on EBP due to urinary concerns, and staff did not don the appropriate PPE during high-contact care. On the observed date, a Certified Nursing Assistant (CNA) entered Resident 2's room wearing only a face mask and gloves, omitting the required gown. This was confirmed by a Licensed Practical Nurse (LPN) and the Minimum Data Set Coordinator (MDSC), who both acknowledged the necessity of a gown for such care. Resident 2, who was not cognitively impaired, also confirmed that staff did not consistently wear PPE when providing care or handling the urinal. Similarly, Resident 3 was on EBP due to wounds and colonized bacteria in the urine. A CNA entered Resident 3's room and assisted with care without wearing the required gown, despite the EBP signage on the door. Resident 3, also not cognitively impaired, confirmed the inconsistency in PPE usage by staff during care. Both residents were aware of their precautionary status and the need for PPE, yet staff failed to adhere to the facility's infection prevention and control program, which mandates the use of PPE according to established policy.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistance for bathing, resulting in a deficiency. The resident, who had chronic obstructive pulmonary disease and diabetes mellitus, was admitted with moderate cognitive impairment and required staff assistance for bathing. The resident was scheduled to receive a shower once weekly on Wednesdays. However, documentation revealed that the resident did not receive scheduled showers on four occasions. Additionally, the resident refused showers on two other occasions, as noted by both the facility and hospice staff. The Director of Nursing confirmed that blanks in the shower documentation indicated the resident did not receive a shower and acknowledged that the resident often refused care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate and timely administration of medication for a resident with chronic obstructive pulmonary disease, lung cancer, and bone cancer. The resident had physician orders for oxycodone to be administered every four hours for pain, with an additional as-needed dose every six hours, provided it was not given with the scheduled dose. However, the Medication Administration Audit Report revealed multiple instances where the scheduled doses of oxycodone were administered late, ranging from over an hour to nearly three hours past the scheduled time. Additionally, there was an instance where the scheduled dose was administered concurrently with the as-needed dose, contrary to the physician's orders. The Director of Nursing confirmed that the facility's policy required medications to be administered within one hour of their scheduled time and acknowledged the discrepancies in the administration of the resident's medication. The resident, who had a moderate cognitive impairment, did not consistently receive pain medication as ordered, which could have impacted their comfort and pain management. The facility's failure to adhere to the medication administration policy and physician orders resulted in a deficiency in providing pharmaceutical services to meet the resident's needs.
Unqualified Dietary Manager
Penalty
Summary
The facility did not designate a person to serve as the food and nutrition services director who met the required qualifications. The Dietary Manager (DM) had not completed an approved dietary manager or food service manager certification course or other related education. During an interview, the DM indicated that they had just started as a cook at the facility and had previous experience working in maintenance and as a cook in an assisted living facility. The DM was enrolled in a ServSafe course, which is not an approved Dietary Manager certification course, and planned to enroll in a dietary manager course after completing the ServSafe course. The Nursing Home Administrator confirmed these details and stated that the facility had a contracted dietician who was onsite every other week.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility did not ensure food was stored and prepared in a safe and sanitary manner, potentially affecting all 42 residents. Staff failed to complete hand hygiene after washing dishes and before touching ready-to-eat food. Specifically, a cook was observed touching potatoes and buns with the same gloved hand that had touched other surfaces, and a dietary aide used the same disposable gloves worn under green gloves to put away clean dishes. Both staff members were unaware of the proper hand hygiene protocols as per the Wisconsin Food Code and the facility's policies. The facility also failed to maintain cleanliness and proper equipment storage. A cook was observed cutting carrots on a counter that had splatters of blood and meat remnants, and the microwave contained dried food and splatter. Additionally, a large mixer was left uncovered. These observations were confirmed by the Dietary Manager, who acknowledged that the equipment should be cleaned and covered as per the Wisconsin Food Code and the facility's policies. Furthermore, the facility did not maintain unit refrigerator and freezer temperature logs, and open items in the walk-in cooler and dry storage area did not contain open dates. During a kitchen tour, the surveyor found undated bags of cereal, cheese slices, cut onions, and a container of liquid eggs. The Dietary Manager confirmed that these items should have been labeled with open dates, as required by the Wisconsin Food Code and the facility's policies.
Inadequate Infection Preventionist Staffing and Training
Penalty
Summary
The facility did not ensure that the designated Infection Preventionist (IP) completed the required infection prevention and control training and was employed at least part-time in the facility. During the entrance conference, the Nursing Home Administrator (NHA) informed the surveyor that the Director of Nursing Mentor (DONM) was overseeing the IP role and mentoring the Assistant Director of Nursing (ADON), who was not yet certified as an IP. Interviews with the Director of Nursing (DON) and DONM revealed that the DONM did not work any scheduled hours in the facility and was more of a consultant. The ADON confirmed that the DONM was the facility's IP but did not work scheduled hours and was only available to assist as needed. The ADON also provided proof of partial completion of the required IP training modules but had not completed all 23 modules. The NHA stated that they were not aware that the IP needed to work at least part-time at the facility. The DON mentioned that they might have IP certification at home but later confirmed via email that they could not find the certification. This lack of a qualified and adequately trained IP working at least part-time in the facility had the potential to affect all 42 residents residing in the facility.
Delay in Pain Management for Resident
Penalty
Summary
The facility did not ensure effective pain management for a resident (R91) who required such services. On 3/18/24, R91, who had a right femur fracture and moderately impaired cognition, experienced significant pain but did not receive timely pain relief. The facility's policy required prompt pain management, but there was a delay in obtaining morphine from the emergency kit due to issues with the pharmacy and communication with the hospice nurse. Despite multiple attempts by the nursing staff to expedite the process, the first dose of morphine was not administered until 7:58 PM, several hours after the initial prescription was received at 3:02 PM. The delay was exacerbated by the facility's reliance on a PIXUS machine for emergency medications, which required an authorization code from the pharmacy. The nurse on duty, RN-N, documented multiple calls to both the hospice and the pharmacy, trying to obtain the necessary prescription and authorization. The pharmacy's response was slow, and the process was further delayed when the pharmacist went on break. The Director of Nursing (DON) acknowledged ongoing issues with the pharmacy, stating that the process for obtaining controlled substances was problematic and often resulted in delays. During the delay, R91 exhibited signs of severe pain, including yelling out and moaning. The resident's family was present and expressed their distress over the situation. The next shift nurse, RN-O, confirmed that R91 was in visible pain and that the family did not want the resident to suffer. The first dose of morphine was finally administered by RN-O after the medication was retrieved from the PIXUS machine, but this was several hours after the initial need for pain relief was identified, resulting in prolonged suffering for R91.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility did not ensure the right to personal privacy for one resident (R21) during personal care. On 5/6/24, a surveyor observed that the window blind in R21's door was open, allowing an unobstructed view of R21's bed from the nurses' station. During this time, an LPN and a CNA were providing personal care to R21, and R21's nude body with genitals exposed was visible to others in the common area around the nurses' station. Two residents of the opposite gender were present near the nurses' station at the time of the observation. Interviews with staff confirmed that the window blind should have been closed to ensure R21's privacy. The LPN involved stated that they did not notice the window blind was open when they began personal care. Both the Nursing Home Administrator and the Director of Nursing verified that it is the facility's expectation to provide visual privacy for residents during personal care, and that the window blind should have been closed to maintain R21's privacy and dignity.
Deficiency in Respiratory Care for Residents Using Oxygen Therapy
Penalty
Summary
The facility did not provide the necessary respiratory care and services for two residents who were using oxygen therapy. One resident, R8, was using humidified oxygen from a concentrator without a physician's order, and their care plan did not address oxygen use. Additionally, R8's oxygen tubing was not labeled to indicate the date it was last changed. During an interview, R8 could not recall the frequency of tubing changes or when it was last changed. The water reservoir chamber for humidification was found to be empty. The Director of Nursing confirmed that there was no order for humidified oxygen or a care plan for oxygen use for R8, and the facility did not have a policy for labeling oxygen tubing, although it was expected to be changed weekly based on best practice. Another resident, R144, was also using oxygen from a concentrator without a physician's order or a care plan addressing the use of oxygen. R144 had moderately impaired cognition and was unable to provide information about the frequency of tubing changes or the oxygen flow rate. The Director of Nursing confirmed that there were no orders for oxygen use or care and management of the oxygen tubing prior to the surveyor's review. Orders were obtained from R144's physician only after the surveyor's findings.
Vaccines Administered Despite Declination
Penalty
Summary
The facility administered COVID-19 and influenza vaccines to a resident (R11) despite the resident's legal guardian having declined the vaccines. R11 was admitted with multiple diagnoses including chronic obstructive pulmonary disease (COPD), multiple sclerosis, type 2 diabetes with neuropathy, and respiratory syncytial virus (RSV) pneumonia. On 1/3/24, R11's legal guardian signed a declination form for both vaccines, but later that same day, the vaccines were administered to R11. This was confirmed through progress notes and the vaccination record, which indicated the specific vaccines and their lot numbers. During an interview, the Director of Nursing (DON) confirmed that the vaccines were administered despite the signed declination forms and progress notes indicating refusal. The DON acknowledged that staff should have reviewed the declination sheets more carefully and recognized the seriousness of administering vaccines against the resident's or legal guardian's wishes. The DON also verified the administration log and immunization record, confirming the error.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, resulting in deficiencies observed in the care of two residents. For Resident 144, a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) when entering the resident's room, despite the presence of a contact precautions sign. Additionally, a Registered Nurse (RN) failed to perform proper hand hygiene and did not disinfect scissors used during wound care for the same resident. The RN admitted to not sanitizing the scissors and not performing hand hygiene between glove changes, citing unfamiliarity with the facility's supply locations as a contributing factor. For Resident 27, a CNA did not follow proper hand hygiene protocols during incontinence care. After removing a soiled incontinence brief and performing perineal care, the CNA did not remove soiled gloves and cleanse hands before touching clean items and equipment in the resident's room. This lapse in protocol was confirmed by the CNA during an interview with the surveyor. The facility's policies on infection prevention, control, and hand hygiene were not adhered to by the staff, as confirmed by the Director of Nursing (DON). The DON acknowledged that staff should wear gowns and gloves when providing care involving resident contact and that hand hygiene should be performed between glove changes and after handling soiled items. The DON also confirmed that reusable equipment should be sanitized before use.
Failure to Offer PCV20 Vaccine to Residents
Penalty
Summary
The facility did not ensure that flu and pneumonia vaccinations were reviewed, offered, or administered for three residents (R7, R11, and R21) as per CDC guidelines. Specifically, these residents were not offered the PCV20 (Prevnar 20) vaccine despite having received previous pneumococcal vaccinations (PPSV23 and PCV13). The medical records for these residents did not indicate that the PCV20 vaccine was offered or administered, which is a deviation from the facility's policy and CDC recommendations. The Director of Nursing (DON) confirmed that the residents should have been offered the PCV20 vaccine and that the documentation should have been included in their medical records. Resident 7, who had diagnoses including congestive heart failure, chronic kidney disease, pneumonia, and type 2 diabetes, received a PPSV23 vaccine in 2016 and a PCV13 vaccine in 2019 but was not offered the PCV20 vaccine. Resident 11, with diagnoses including COPD, multiple sclerosis, type 2 diabetes with neuropathy, and RSV pneumonia, received a PPSV23 vaccine in 2013 and a PCV13 vaccine in 2022 but was also not offered the PCV20 vaccine. Resident 21, diagnosed with Parkinson's disease, cancer, and dementia, received a PPSV23 vaccine in 2017 and a PCV13 vaccine in 2016 but was not offered the PCV20 vaccine. The DON acknowledged that the facility's vaccine policies and procedures need attention and that the PCV20 vaccination information was not included on the facility's consent/declination form.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure adequate fall prevention interventions for three residents. One resident, admitted with a left femur fracture and severe dementia, experienced multiple falls within a short period. Despite the falls, the facility did not implement new interventions promptly, and the resident fell again. The Director of Nursing confirmed that new interventions should have been added to the resident's care plan following the falls. Another resident, admitted after a fall at home resulting in a left femur fracture and hip surgery, had a rug with curled edges in their room, posing a trip hazard. The facility did not develop a comprehensive falls care plan that included the resident's preference and risk for keeping the rug. Staff expressed concerns about the rug, but no risk versus benefit statement was completed, and the care plan lacked detailed interventions. A third resident, with a history of tobacco dependence and brain cancer, required supervised smoking. However, smoking materials were found unsecured in the resident's room. Staff interviews revealed a lack of awareness and adherence to the facility's smoking policy, which mandates that smoking materials be kept locked in the medication cart.
Failure to Ensure QAPI Committee Meetings and Attendance Verification
Penalty
Summary
The facility did not ensure the minimum required members of the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly, as mandated. The facility failed to hold two of the four required QAPI meetings in the past year and six of the twelve monthly meetings per their policy. Additionally, for the two required QAPI meetings that were held, the facility was unable to provide verification of attendance for the required members. This deficiency had the potential to impact all 42 residents residing in the facility. Upon review, the surveyor found that the QAPI committee meeting sign-in sheets for the previous year were incomplete and lacked signatures. The facility's policy indicated that a core team, including the Executive Director, Director of Nursing, and other key personnel, should engage in monthly QAPI meetings. However, sign-in sheets for several months were missing, and the available sheets did not contain signatures. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the absence of proper documentation and attendance verification for the QAPI meetings.
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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