Sun Prairie Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Sun Prairie, Wisconsin.
- Location
- 228 W Main St, Sun Prairie, Wisconsin 53590
- CMS Provider Number
- 525380
- Inspections on file
- 16
- Latest survey
- June 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sun Prairie Senior Living during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, anxiety, and diabetes who required extensive assistance with ADLs did not have a comprehensive care plan with specific approaches for staff to follow. Staff interviews confirmed the absence of documented interventions in the care plan and resident profile, despite facility policy requiring such documentation.
Two residents requiring assistance of two staff members for transfers were inadequately assisted by a single CNA, contrary to their care plans. One resident, with chronic heart failure and knee replacements, and another with heart disease and dementia, were transferred solo by the CNA, despite needing two-person assistance. The DON confirmed the requirement for two staff members during transfers.
The facility did not have an RN on duty for 8 consecutive hours on a specific day, as required. A review of staff schedules showed no RN was present for any shift on that day, and the DON confirmed the absence was due to a call-in. This affected all 33 residents in the facility.
The facility failed to maintain food safety and sanitation standards, affecting all residents. Staff were observed preparing food without proper hair restraints, and the facility did not record dishwasher temperature checks. Expired food items and dented cans were found in circulation, and unlabeled food was observed, indicating non-compliance with FDA and facility policies.
The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, with lapses in contact tracing, testing, and PPE use. Staff did not adhere to proper infection control practices, such as wearing PPE and performing hand hygiene. A resident's urinary catheter was improperly managed, potentially contributing to infections. These deficiencies could affect the entire resident census.
A resident with moderate cognitive impairment was taken to breakfast in her pajamas against her expressed wishes, compromising her dignity. The CNAs prioritized other tasks and did not consult the resident, leading to feelings of embarrassment and a violation of resident rights. Staff acknowledged the dignity issue, recognizing the importance of respecting resident preferences.
A resident on hospice care expressed concerns about the cleanliness of her room, which was confirmed by a surveyor's observations of dust and debris. The Environmental Services staff cited insufficient housekeeping staff, and there was no system to track room cleaning. The Nursing Home Administrator acknowledged the expectation for daily cleaning but admitted there was no verification system in place.
A resident with a Stage III pressure ulcer did not receive necessary care as they spent five hours in a wheelchair without a pressure-relieving cushion. Additionally, an air mattress was used without staff knowledge of proper inflation, as there were no instructions or education provided. The DON confirmed that the mattress would not be effective if not properly inflated.
A resident at moderate risk for falls experienced multiple falls due to inadequate supervision and delayed interventions. The facility failed to document falls, update medical personnel, or implement individualized interventions. Despite knowing the resident's preferences for sleeping in a recliner with lights and TV on, the facility did not incorporate these into the care plan, leading to repeated falls while waiting for a scoop mattress.
A resident with a right humerus fracture experienced inadequate pain management due to the facility's failure to obtain prescribed narcotics and address the resident's refusal of uncoated acetaminophen. The care plan lacked specific pain tolerance levels and non-pharmacological interventions. Staff did not communicate effectively to resolve the missing prescription or the resident's medication preferences, resulting in ongoing pain and distress.
A LTC facility experienced a 16% medication error rate during a medication pass task, affecting three residents. Errors included late administration of Tylenol and vitamins, and improper timing of insulin administration relative to meals. The facility's policy and best nursing practices were not followed, as confirmed by the DON and CRN.
A resident who initially refused the influenza vaccine upon admission was not offered the vaccine again during the current flu season, contrary to the facility's policy. The resident's medical record lacked documentation of subsequent offers or education about the vaccine, as confirmed by the CRN and DON during an interview.
Failure to Develop Comprehensive, Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the medical, physical, mental, and psychosocial needs of a resident with multiple diagnoses, including dementia, chronic pain, anxiety, and type 2 diabetes. The resident required significant assistance with activities of daily living (ADLs), such as eating, hygiene, dressing, transfers, and was frequently incontinent of urine and bowel. Despite these needs, the resident's comprehensive care plan and resident profile lacked specific approaches or interventions for staff to follow, leaving essential care areas such as incontinence, ADLs, blood glucose management, pain, and anxiety unaddressed in the care plan documentation. Interviews with CNAs revealed that staff relied on the resident profile for care instructions, but were unable to find any approaches for the resident in question. Both the Nursing Home Administrator and Director of Nursing acknowledged the absence of care plan approaches and confirmed that they should have been present. The facility's own policy required that care plans be comprehensive, person-centered, and regularly updated to reflect the resident's needs, but these requirements were not met for this resident.
Inadequate Staff Assistance During Resident Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents, R6 and R5, by not adhering to the required staff assistance during transfers. R6, who has chronic diastolic heart failure, anxiety disorder, and bilateral artificial knee joints, was care planned for pivot transfers with the assistance of two staff members using a gait belt or walker. However, R6 reported that sometimes only one staff member assisted with transfers, and CNA C admitted to performing solo transfers for R6, despite the care plan's requirements. Similarly, R5, who has atherosclerotic heart disease and vascular dementia, was care planned to require a Hoyer lift and assistance from two staff members for all transfers. Despite this, CNA C acknowledged transferring R5 alone when other staff were unavailable. The Director of Nursing confirmed that both R6 and R5 should have been transferred with the assistance of two staff members, as per their care plans. This failure to follow the care plans and ensure adequate staff assistance during transfers led to the deficiency identified by the surveyors.
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 on January 1, 2025, as required by regulations. This deficiency was identified during a review of nursing staff schedules and postings from December 23, 2024, to January 6, 2025, which revealed that no RN was scheduled or present for any of the three shifts on that day. The Director of Nursing (DON) confirmed during an interview that an RN was expected to be in the building every day for at least 8 consecutive hours and acknowledged that the scheduled RN had called in, resulting in the absence of RN coverage. This oversight had the potential to affect all 33 residents residing within the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 33 residents. Surveyors observed multiple instances of non-compliance with food safety standards. Staff members, including the Director and Assistant Director of Food Services, were seen preparing meals without proper hair restraints, despite the facility's policy requiring hair over 1/8 of an inch to be covered. Additionally, the facility did not maintain records of manual temperature monitoring for the dishwasher, as required by their policy, which could compromise the sanitation of dishware. Further observations revealed that the facility had expired food items, such as cottage cheese and V8 juice, still in circulation, and dented cans of tuna and creamed corn were not discarded as per policy. There was also an instance of a food item being removed from its original packaging without proper labeling or dating. These deficiencies indicate a lack of adherence to professional standards for food safety and sanitation, as outlined by the FDA Food Code 2022 and the facility's own policies.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, which was evident during a COVID-19 outbreak. The facility did not conduct contact tracing or complete appropriate testing of residents and staff. The staff line list was incomplete, missing information such as the last day worked and the area worked in, which hindered the facility's ability to track and trend staff illnesses. Additionally, the facility's outbreak policy was not clearly understood by the staff, as evidenced by the lack of documentation for contact tracing and testing during the outbreak. Multiple instances of staff not adhering to proper infection control practices were observed. Staff members were seen not wearing appropriate personal protective equipment (PPE) when administering eye drops to a resident and when providing care to a resident under enhanced barrier precautions. Furthermore, a CNA was observed using a personal cell phone and then assisting a resident with a meal without performing hand hygiene in between, which is a breach of infection control protocols. The facility also failed to manage a resident's urinary catheter properly, as it was observed in direct contact with the wheel of the resident's wheelchair while in motion. This resident had a history of recurrent urinary tract infections, and the catheter's improper handling could contribute to further infections. These observations highlight significant lapses in the facility's infection prevention and control measures, potentially affecting the entire resident census.
Resident Dignity Compromised During ADLs
Penalty
Summary
The facility failed to ensure that a resident, identified as R13, was treated with dignity and respect during the provision of activities of daily living (ADLs). R13, who has moderate cognitive impairment and was admitted with diagnoses including anorexia, weakness, and adult failure to thrive, expressed a preference not to be taken to the dining room in her pajamas. Despite this, the staff transferred R13 to breakfast in her pajamas, which made her feel like a low-class citizen and compromised her sense of vanity. The incident occurred because the certified nursing assistants (CNAs) were running behind schedule and prioritized other tasks, such as assisting residents who were going home that day, over R13's expressed preferences. The CNAs decided not to dress R13 before breakfast to avoid undressing her again for a shower scheduled after breakfast. This decision was made without consulting R13, who felt terrible and embarrassed when another resident commented on her attire. The facility's failure to respect R13's preferences and dignity was acknowledged by the staff, including a Clinical Registered Nurse (CRN) and the Director of Nursing (DON), who agreed that the situation could be considered a dignity issue and a violation of resident rights. The facility's documentation on resident rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this instance.
Failure to Maintain Clean and Comfortable Environment for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for a resident, identified as R18, who was on hospice care and had diagnoses including metabolic encephalopathy and depression. R18, who was cognitively intact, expressed concerns about the cleanliness of her room, noting that it was not cleaned often. The surveyor observed dust accumulation on various surfaces in R18's room and debris on the carpeting. R18 reported that her room had not been cleaned for a couple of weeks and that housekeeping did not clean her room daily. The Environmental Services staff member, ES Q, confirmed the lack of regular cleaning, citing insufficient housekeeping staff and indicating that R18's room was cleaned last. There was no sign-off sheet to track when rooms were cleaned, and the Nursing Home Administrator (NHA A) acknowledged the expectation for daily cleaning but admitted there was no current system to verify this. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to maintain a sanitary and orderly environment for R18.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident, who has a Stage III pressure ulcer on the sacrum, spent approximately five hours sitting in a wheelchair without a pressure-relieving cushion during an appointment. This was contrary to the facility's guidelines, which require pressure-reducing cushions for residents at risk of pressure ulcers. Interviews with staff confirmed that the resident should have had a cushion in the wheelchair, but it was not provided. Additionally, an air mattress was placed on the resident's bed without staff knowledge of the manufacturer's recommendations for proper inflation. The air mattress was obtained from storage, and staff, including the maintenance team, were unaware of the brand or the correct amount of air required for effective use. The Director of Nursing acknowledged that the mattress would not be effective if not properly inflated, which could potentially cause harm. The lack of instructions and staff education on the use of the air mattress contributed to the deficiency.
Failure to Prevent Falls and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as R16, who was at moderate risk for falls. R16 experienced multiple falls within the facility, and the staff did not document the details of these falls, nor did they update the resident's medical doctor or power of attorney. Additionally, the facility did not initiate neuro checks according to its policy, and a Registered Nurse Assessment post-fall was not recorded. The facility also failed to identify the root causes of R16's falls and did not implement individualized interventions to prevent further incidents. R16's care plan was not adequately updated to reflect the resident's needs and preferences, such as sleeping in a recliner and having the lights and TV on, which were known to the staff but not acted upon. Despite the resident's family reporting these preferences, the facility did not incorporate them into the care plan or attempt alternative interventions while waiting for a scoop mattress to arrive. This delay in obtaining the scoop mattress, coupled with the lack of increased supervision or alternative measures, resulted in R16 experiencing additional falls. The facility's policy on fall management was not followed, as evidenced by incomplete documentation of fall events and a lack of thorough investigation into the causes of the falls. The facility did not engage in a comprehensive review by the interdisciplinary team to evaluate the appropriateness of interventions. The staff's failure to recognize and address the resident's specific needs and preferences contributed to the repeated falls and the facility's inability to prevent further accidents.
Inadequate Pain Management for Resident with Fracture
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as R182, who was admitted with a right humerus fracture and other medical conditions such as type 2 diabetes and neuropathy. Upon admission, R182 had orders for various pain medications, including oxycodone, acetaminophen, lidocaine patches, and Voltaren gel. However, the facility did not obtain the ordered narcotics, and R182 began refusing acetaminophen due to difficulty swallowing, leading to continued pain. The facility's policy on pain management was not followed, as there was a lack of documentation regarding pain assessments and interventions. R182 experienced significant pain, with documented pain ratings reaching as high as 7 out of 10. Despite this, the facility did not ensure timely access to prescribed medications, such as oxycodone, and failed to address the resident's refusal of acetaminophen due to its uncoated form causing discomfort. The care plan for R182 was incomplete and did not specify the resident's pain tolerance level or preferred non-pharmacological interventions. Additionally, there was a delay in obtaining a new order for coated acetaminophen tablets, which the resident preferred. Interviews with facility staff revealed that there was a lack of communication and follow-up regarding the missing oxycodone prescription and the resident's refusal of acetaminophen. The nursing staff did not notify the physician or the on-call provider about the need for a new prescription or the resident's medication preferences. The Director of Nursing acknowledged that the staff should have confirmed the receipt of the oxycodone script with the pharmacy and taken steps to address the resident's medication refusal. This deficiency in pain management resulted in R182 experiencing ongoing pain and distress.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 16% error rate during a medication pass task. Three errors were identified among 25 opportunities, affecting three residents. The errors included late administration of medications and improper timing related to meal administration. Specifically, one resident received Tylenol significantly later than the prescribed time, another resident received Vitamin B-12 and Vitamin D3 late, and a third resident received short-acting insulin without receiving a meal within the required timeframe. The first resident, who has severe cognitive impairment and multiple diagnoses including dementia and polyosteoarthritis, was supposed to receive acetaminophen at 7:00 AM but was administered the medication at 8:42 AM. The Director of Nursing confirmed that this was a medication error as it was not documented that the resident refused the medication at the scheduled time. The second resident, who is cognitively intact and has cerebrovascular disease and chronic systolic heart failure, received their vitamins at 8:51 AM instead of the scheduled 7:00 AM, which was also confirmed as a medication error by the Director of Nursing. The third resident, with moderate cognitive impairment and diagnoses of Type 2 Diabetes Mellitus and Major Depressive Disorder, received insulin aspart 49 minutes before receiving a meal, contrary to the best nursing practice of administering short-acting insulin 15 minutes before meals. The Clinical Registered Nurse confirmed that the resident should have received their meal within 15 minutes of the insulin administration. These errors highlight a failure to adhere to the facility's medication administration policy and best nursing practices.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to offer influenza immunizations to a resident, identified as R16, during the current flu season, as required by their policy. R16 was admitted to the facility and initially refused the influenza vaccine upon admission, as documented in the Admission Immunization Consent Packet. However, there was no evidence in R16's medical record that the influenza vaccine was offered again during the current flu season, nor was there documentation of any education provided regarding the risks and benefits of the vaccine. During an interview, the Clinical Registered Nurse (CRN I) and the Director of Nursing (DON B) confirmed that the facility's process involves offering the vaccine at least three times and providing education if initially declined. This process should be documented in the progress notes. Despite this protocol, R16's medical record lacked documentation of any subsequent offers or education about the influenza vaccine after the initial refusal, indicating a failure to adhere to the facility's immunization policy.
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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