Sunrise Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 3540 S 43rd St, Milwaukee, Wisconsin 53220
- CMS Provider Number
- 525493
- Inspections on file
- 33
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Sunrise Health Services during CMS and state inspections, most recent first.
A resident with stroke, diabetes, COPD, CHF, pulmonary hypertension, right-sided weakness, aphasia, and dependence on staff for toileting was the subject of a neglect allegation after a family member reported the resident was not being changed, was spoken to rudely by a CNA, and was not given water. The facility’s investigation documentation did not show that other residents were interviewed about their care by CNAs, despite policy requiring interviews of all involved persons and others who might have knowledge of the allegation. The DON later produced resident interviews, but follow-up revealed these were conducted weeks later rather than at the time of the incident, and the Administrator acknowledged that resident interviews were not obtained during the original investigation.
Surveyors observed that insulin pens and vials on a medication cart were not properly labeled with resident names or dates opened, and some were expired. An LPN was unable to clarify labeling discrepancies or expiration periods, and the facility's policy for labeling and discarding insulin after 28 days was not followed. These findings were shared with the administrator and DON, but no additional information was provided.
The facility did not ensure that residents had ongoing access to their personal funds, as withdrawals could only be made during limited weekday hours when designated staff were present. No petty cash was available for evenings, weekends, or holidays, and there was no posted information about fund access, affecting multiple residents whose funds were managed by the facility.
A resident with multiple comorbidities and high risk for pressure injuries was admitted without any skin breakdown, but the facility failed to develop and implement a comprehensive skin integrity care plan. Staff did not consistently perform required foot inspections, repositioning, or offloading of heels, and treatments for multiple pressure injuries were delayed. Observations and interviews revealed that care plan interventions such as Prevalon boots were not routinely used, and documentation of care was incomplete, resulting in the development and delayed treatment of several pressure injuries.
Seven staff members, including a dietary aide, an LPN, five CNAs, and a contracted speech language pathologist, did not receive required behavioral health training as outlined in the facility's assessment. The facility lacked documentation and a formal policy for such training, despite having a significant percentage of residents with psychiatric diagnoses. The only training provided was an inservice on abuse, which did not address the specific behavioral health needs of the resident population.
A resident requiring CPR was attended to by staff, including an LPN whose CPR certification had expired, contrary to facility policy requiring current certification and availability of CPR-certified staff at all times. The facility was unable to promptly verify staff certification status, and emergency responders noted low-quality CPR was being performed.
A resident with a left patella fracture and Parkinson's disease experienced frequent displacement of a knee immobilizer, which staff routinely readjusted but did not report or escalate to the physician. Despite facility policy requiring monitoring and documentation of assistive device issues, staff did not assess or address the risk, leading to failure of the surgical repair as confirmed by the orthopedic surgeon.
A resident with severe cognitive impairment and a history of falls was left alone on the toilet by a CNA, despite care plan instructions requiring assistance. The resident attempted to self-transfer and experienced an unwitnessed fall. Facility documentation inconsistently identified the resident's fall risk, and a required post-fall assessment was not completed.
A resident with chronic kidney disease and other conditions did not receive an updated sodium bicarbonate dosage as ordered by a nephrologist, due to the facility's failure to process the new order. Additionally, staff left medications for a family friend to administer, contrary to facility policy, and there was no documentation or care plan supporting this practice.
A resident fell from bed and was found unresponsive due to the facility's failure to ensure the bed was in a low position and provide adequate supervision. The resident's care plan required a low bed due to fall risk, but the bed was elevated for television viewing without necessary safety adjustments. The resident suffered positional asphyxia and other injuries, resulting in death.
A facility failed to provide appropriate treatment and services for a resident with dementia, leading to escalated behavioral symptoms and an incident where the resident ran over another resident's foot with a wheelchair. Despite significant behavioral changes, the facility did not conduct a comprehensive assessment or timely revise the care plan, resulting in immediate jeopardy.
The facility failed to notify a resident's POA when a CBC and UA were ordered. The resident, with severe impairment and multiple diagnoses, had a POA activated, but the facility did not inform the POA as required by their policy. The lapse was confirmed through interviews and record reviews.
A resident with Alzheimer's and severe impairment sustained a left forearm fracture and had a purple, painful right middle toe. The facility failed to consistently monitor these injuries or update the care plan, despite multiple staff notes and the resident's complaints of pain. The resident was eventually discharged to the hospital with noted bruising and swelling.
A resident was not provided timely therapy services as required by physician orders and facility policy. Despite multiple diagnoses and a decline in condition, the necessary evaluations for speech, physical, and occupational therapy were not conducted, leading to a deficiency.
The facility failed to inspect and maintain bed frames and rails according to the Manufacturer's Instructions for Use, affecting four residents and potentially all 94 residents using beds. The Maintenance Director did not document inspections for occupied beds, contrary to facility policy and manufacturer guidelines.
The facility failed to properly label and store medications, with surveyors finding expired and unlabeled medications in two medication carts and one medication room. Medications such as eye drops and liquid medications lacked open dates, and expired medications were not removed from stock. Additionally, cleanliness issues were noted in the second-floor medication cart.
A resident who went out on therapeutic leave was not allowed to return to the facility due to lack of communication and absence of a bed hold policy. Despite multiple attempts to arrange her return, the facility considered her absence as a self-discharge and did not provide proper notice or consider her unstable housing situation.
The facility failed to attempt alternatives to bed rails and did not obtain informed consent for their use in two residents with moderate cognitive impairment. The facility's policy requires documentation of attempted alternatives and informed consent, which was not followed, putting residents at risk.
The facility failed to provide written transfer or discharge notices to six residents and their representatives, as required by policy and regulation. These notices should have included the reason for transfer, the place of transfer, and information on how to appeal the transfer. The deficiency was identified during a review of records, interviews, and policy examination, revealing that the facility did not adhere to its own policy of notifying residents and their representatives in writing, especially in cases of emergent hospital transfers.
Failure to Conduct Timely and Thorough Neglect Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident. The resident had been readmitted with diagnoses including stroke and diabetes, and had an ADL care plan indicating an ADL self-care deficit related to COPD, CHF, pulmonary hypertension, right-sided weakness, and aphasia, with an intervention requiring assist of two for toileting. A significant change MDS with an ARD of 01/16/26 showed the resident had a BIMS score of 10/15, indicating moderately impaired cognition, and was dependent on staff for toileting. A facility investigation dated 01/14/26 documented that a family member reported the resident had not been changed, was calling more often to express concerns, that a CNA spoke to the resident in a rude manner, and that water was not given to the resident. Review of the investigation file showed no evidence that other residents had been interviewed to determine if they had concerns about care provided by CNAs, despite the facility’s abuse, neglect, and exploitation policy requiring identification and interviews of all involved persons, including others who might have knowledge of the allegations. When the DON was asked about resident interviews, the DON later produced interviews but stated they were thought to be in another folder. Follow-up on 02/23/26 revealed that the identified residents had actually been interviewed on that date, not at the time of the original investigation. On 02/25/26, the Administrator acknowledged that resident interviews were not obtained at the time of the investigation, demonstrating that the facility did not conduct an immediate and complete investigation as required by its policy.
Insulin Labeling and Expiration Deficiencies on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards and facility policy. During observation of a medication cart, an aspart insulin pen was found with two different dates written on it, and the LPN present was unable to clarify which date was correct. Additionally, a Humalog insulin pen was discovered without a resident name label, and a Lispro insulin vial was found with a date indicating it was expired. The LPN was unsure about the correct expiration period for insulin and acknowledged that the insulins observed were expired. The facility's policy requires that multi-dose vials be labeled with the date opened and the initials of the first user, and that insulins such as Humalog and Aspart be discarded 28 days after opening. The surveyor discussed these findings with the Nursing Home Administrator and the Director of Nursing, but no further information was provided to address the labeling and expiration concerns identified during the inspection.
Failure to Provide Residents Ongoing Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had consistent access to their personal funds held by the facility, as required by federal and state regulations. According to interviews and record review, the Business Office Manager (BOM) was primarily responsible for managing resident funds and was typically available only during weekday business hours. The Social Services Coordinator (SSC) also had access to the safe but worked limited weekday hours. Neither the BOM nor the SSC were present during evenings, weekends, or holidays, and there was no petty cash fund available for residents to withdraw money during these times. The facility did not have posted banking hours or information regarding the availability of funds for withdrawal. Staff interviews confirmed that if residents wanted to access their funds outside of the BOM or SSC's working hours, they would need to plan ahead, as there was no system in place to accommodate requests during evenings, weekends, or holidays. The Administrator acknowledged that there had never been an instance where a resident requested funds during these times, but also recognized the lack of a process for such situations. At the time of the survey exit, the facility had not provided additional information to explain why residents did not have ongoing access to their funds, affecting 42 residents whose personal funds were managed by the facility.
Failure to Prevent and Treat Pressure Injuries in High-Risk Resident
Penalty
Summary
A resident was admitted to the facility without any pressure injuries but was identified as being at high risk for pressure injury development due to multiple comorbidities, including diabetes mellitus, chronic kidney disease, and peripheral vascular disease. Despite this high risk, the facility failed to develop a comprehensive skin integrity care plan upon admission, and the care plans in place did not address necessary interventions such as repositioning or offloading of the resident's feet and heels. The facility's own policy required a baseline plan of care and interventions based on risk factors, but these were not implemented in a timely manner. Additionally, staff did not consistently inspect the resident's feet as required, and documentation of these assessments was lacking in the medical and treatment administration records. The resident subsequently developed multiple pressure injuries, including unstageable pressure injuries and suspected deep tissue injuries on the right ankle, heel, inner ankle, top of the right foot, and right toe. These injuries were not identified and treated promptly; treatments were not ordered until two days after the injuries were first documented. Furthermore, the treatment administration records did not show that ordered treatments were completed on the initial days following the orders. Observations during the survey revealed that the resident was frequently not wearing Prevalon boots as required by the care plan, and her heels were often not offloaded, with staff failing to implement these interventions during routine care and repositioning. Interviews with staff indicated a lack of awareness regarding the resident's care plan requirements, and some staff reported difficulty providing care due to the resident's pain and cognitive impairment. Family members also reported that staff were not consistently providing incontinence care or repositioning the resident as required. The facility's failure to provide necessary care and services to prevent the development and promote the healing of pressure injuries, as well as the failure to develop and update appropriate care plans, led to the finding of Immediate Jeopardy.
Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that seven randomly selected staff members, including a dietary aide, an LPN, five CNAs, and a contracted speech language pathologist, received behavioral health training as required by the facility's own assessment and regulatory standards. The facility was unable to provide documentation of behavioral health training for these staff members, nor did it have a policy or procedure outlining training requirements for all employees and contracted personnel. The facility assessment, last reviewed on 8/5/24, indicated that staff should be educated on caring for residents with mental and psychosocial disorders, trauma, and psychiatric diagnoses, but behavioral health was not listed as a training topic in the assessment. The assessment also documented that approximately 57% of residents had a psychiatric diagnosis, including anxiety, bipolar disorder, mood disorder, schizoaffective disorder, schizophrenia, depression, and developmental disorder. During interviews, the nursing home administrator confirmed that there was no formal behavioral health training in place to address the needs of residents with psychiatric diagnoses or behavioral health issues. The administrator also stated that monitoring of required trainings had been the responsibility of human resources, but this role had recently shifted to the administrator. The only documentation provided related to an inservice on abuse, which did not include specific training on the psychiatric diagnoses present in the facility or interventions tailored to those conditions.
Failure to Ensure CPR-Certified Staff Available and Aware of Certification Status
Penalty
Summary
The facility failed to ensure that staff responsible for providing CPR were properly certified and that the status of staff CPR certifications was accurately tracked and known. During an incident where a resident was found unresponsive and without a pulse, staff initiated CPR as per the resident's documented wishes and physician orders. However, one of the first responders, an LPN, was not currently certified in CPR at the time of the event, as their certification had expired the previous year. The facility's policy required that CPR-certified staff be available at all times and that staff maintain current certification, but the facility was unable to provide documentation confirming the certification status of all staff involved, and the Human Resources department responsible for tracking certifications was in disarray due to recent staff turnover. Interviews with facility staff revealed a lack of awareness regarding which staff members were CPR certified, and the Director of Nursing was still in the process of gathering certification records after the event. The quality of CPR performed was noted as low by emergency responders, and the resident ultimately passed away. The deficiency was further highlighted by the facility's inability to promptly produce a list of CPR-certified staff and the admission by the LPN involved that their certification had lapsed.
Failure to Address and Report Knee Immobilizer Issues Resulting in Poor Surgical Outcome
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care and treatment in accordance with their care goals and physician orders, specifically regarding the use of a knee immobilizer following surgical repair of a left patella fracture. The resident, who had Parkinson's disease with associated tremors and spasms, required the immobilizer to be worn at all times except for skin checks. Despite this, the immobilizer frequently slipped out of place due to the resident's involuntary movements and activity level, which was observed and acknowledged by multiple staff members, including PT, CNA, RN, and DON. Staff routinely readjusted the immobilizer but did not document the issue or notify the resident's physician or orthopedic surgeon about the persistent problem. The facility's policy required staff to monitor the consistent and safe use of assistive devices, document problems, and modify the care plan as needed. However, staff did not assess the risk posed by the immobilizer's frequent displacement, nor did they implement or document interventions to address this risk. Interviews revealed that staff considered the slipping to be a normal consequence of the resident's condition and activity, and did not escalate the issue or seek alternative solutions, such as consulting with the physician about the appropriateness of the device or requesting a different immobilizer. As a result, the resident's surgical repair failed, with the orthopedic surgeon attributing the failure to the immobilizer not being in the correct position, which allowed the knee to flex and compromised healing. The lack of recognition, assessment, and intervention regarding the immobilizer's fit and function directly contributed to the poor outcome for the resident.
Resident Left Unattended During Toileting Resulting in Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, and significant physical limitations was left unattended while toileting, resulting in an unwitnessed fall. The resident required partial to maximal assistance for toileting and transfers, as documented in the care plan and assessments. Despite these documented needs, a CNA placed the resident on the toilet and instructed her to use the call light when finished, then left her alone. The resident subsequently attempted to self-transfer and fell, which was later discovered by staff responding to calls for help. The facility's documentation and assessments were inconsistent and did not accurately reflect the resident's fall risk status. The Admission Evaluation and subsequent Quarterly Clinical Reviews failed to identify the resident as being at risk for falls, despite a documented history of falls prior to admission and an unwitnessed fall occurring during the resident's stay. The care plan did include interventions such as not leaving the resident alone during toileting and providing assistance with transfers, but these were not followed at the time of the incident. Additionally, after the unwitnessed fall, the facility did not complete a post-fall assessment as required by its own policy. Staff interviews confirmed that the resident was left alone despite her need for assistance and severe cognitive impairment. The lack of accurate fall risk identification, failure to follow the care plan, and omission of a post-fall assessment contributed to the deficiency identified by surveyors.
Failure to Provide Pharmaceutical Services and Proper Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with multiple chronic conditions, including chronic kidney disease, diabetes mellitus, depressive disorder, anxiety disorder, and restless leg syndrome. A nephrology order was issued to increase the resident's sodium bicarbonate dosage to 1300 mg three times daily, but the facility did not process or implement this order. Instead, the facility continued administering the previous lower dose until a later change was made, and there was no documentation explaining why the new order was not transcribed or acted upon. The Unit Manager was unaware of the missed order and could not provide a reason for the failure to update the medication regimen as directed by the nephrologist. Additionally, the facility did not ensure that medications were administered according to policy, which requires that only authorized personnel administer medications and that the person who prepares the dose is the one who administers it. On observation, a medication cup containing pudding and crushed medication was left on the resident's over-bed table, and a family friend stated that the nurse left the medication for her to administer to the resident. Staff interviews confirmed that it was common for family or friends to be left with the responsibility of giving medications when the resident was resistant, despite the facility's policy prohibiting this practice. There was no evidence in the medical record of any education provided to the family or family friend regarding medication administration, nor was there a care plan addressing this practice. The Director of Nursing confirmed that medications should not be left for family or friends to administer, yet this had occurred on multiple occasions. The facility did not provide an explanation for why the medication order was not processed or why the medication was left for a non-staff member to administer.
Failure to Ensure Resident Safety and Adequate Supervision
Penalty
Summary
The facility did not ensure that a resident was as free of accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents, resulting in a fall from bed. The resident was found unresponsive on the floor next to their bed, with no pulse. The medical examiner's preliminary autopsy report indicated that the resident suffered from possible positional asphyxia, a small epidural hemorrhage of the spinal cord, and hemorrhage of the posterior right neck soft tissue, which resulted in the resident's death. The resident's care plan required them to be in a low bed due to being a fall risk, but at the time of the incident, the bed was not in the low position, and the head of the bed was elevated. Staff were aware that the resident leaned to the right when in bed and had no trunk support, making it difficult for the resident to reposition themselves or stop from rolling. However, no interventions were put in place to create a barrier to prevent the resident from rolling out of bed. Additionally, the resident's television was positioned in a way that required the bed to be elevated for the resident to watch it, but no environmental adjustments were made to ensure the resident's safety while watching television. The facility's Fall Prevention and Management Guidelines policy required each resident to be assessed for fall risk and to receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls and reduce the possibility/severity of injury. The resident had multiple diagnoses, including hypertensive heart disease, type 2 diabetes mellitus, anemia, chronic atrial fibrillation, and vascular dementia. The resident's care plan included interventions such as keeping the bed in a low position, having commonly used articles within easy reach, and reinforcing the need to call for assistance. However, the facility failed to follow these interventions consistently. The resident's bed was not in the low position at the time of the incident, and the head of the bed was elevated, which contributed to the resident's fall and subsequent death. Interviews with staff members revealed that the resident was known to lean to the right when in bed and required assistance with mobility and personal care. The resident's bed was often elevated to allow them to watch television, but no adjustments were made to ensure the resident's safety while in this position. The facility's investigation into the incident did not provide specific details about the bed's position at the time of the fall, and there was no standard practice for what level from the ground was considered a low bed. The facility's failure to address the resident's positioning needs and ensure the bed was in the low position created a reasonable likelihood of serious harm, leading to a finding of immediate jeopardy.
Removal Plan
- Nursing staff will receive re-education on the Fall prevention and Management Guideline Policy. Education will include but is not limited to: Each resident's risk factors will be evaluated when developing an individualized plan of care, Interventions will be monitored for effectiveness, Monitoring changes in residents condition including balance and positioning
- Re-education was initiated and will continue prior to employees next shift to work.
- Staff will receive re-education on definition of low bed and bed in low position
- The ED, DON, and VPS reviewed the Fall Prevention and Management Guidelines policy and determined the policy identifies the compliance guidelines to provide services to minimize the likelihood of falls or reduce the possibility/severity of injury. No changes were required.
- Nursing management will re-evaluate residents with a care plan for bed in low position to determine if intervention is appropriate. Care plans will be updated based on the findings of the evaluations.
- DON and/or designee will complete audits on new admissions to ensure resident's at risk for falls have plans of care that are individualized and implemented by staff.
- DON and/or Designee will review 24 Hour Nursing Report/EMR Clinical Alerts to identify residents with a change of condition resulting in the need to re-evaluate fall risk and interventions.
- DON and/or Designee will audit Residents per week to determine if fall interventions are in place as per plan of care
- Results of the audits will be brought to QAPI for further review and recommendations.
- ADHOC QAPI held with IDT and Medical Director telephonically.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, leading to an escalation of behavioral symptoms. The resident, who has a diagnosis of Alzheimer's disease and dementia, exhibited significant behavioral changes starting on 4/4/24, including verbal and physical aggression towards staff and other residents. Despite these changes, the facility did not conduct a comprehensive assessment to identify the cause of the behavior, nor did they revise the care plan in a timely manner. This lack of assessment and intervention resulted in the resident chasing another resident down the hall and running over their foot with a wheelchair. The facility's medication administration records for December 2023 through March 2024 did not document any behaviors, despite the resident's known history of behavioral symptoms. The care plan, which included interventions such as administering medications per physician orders and attempting psychotropic drug reduction, was not effectively implemented or monitored. The facility also failed to conduct dementia or trauma assessments, which are crucial for understanding and managing the resident's behavior. Interviews with staff revealed that the resident's behavior was not consistently documented or addressed. Staff reported that the resident was often verbally abusive, refused medications, and exhibited physical aggression. Despite these reports, there was no evidence of a coordinated effort to reassess the resident's condition or update the care plan. The facility's failure to comprehensively assess and manage the resident's behavior created an immediate jeopardy situation, which was identified on 4/24/24 and removed on 4/25/24, although the deficient practice continued at a severity/scope level of E (potential for harm/pattern).
Failure to Notify POA of New Treatment Orders
Penalty
Summary
The facility failed to notify a resident's power of attorney (POA) when a new treatment was ordered. Specifically, the POA was not informed when a complete blood count (CBC) and urinalysis (UA) were ordered for the resident on April 7, 2024. The resident, who has diagnoses including Alzheimer's disease, depression, anxiety disorder, and dementia, had a severe impairment as indicated by a BIMS score of 7. The resident's POA was activated on April 27, 2022, and should have been notified according to the facility's policy on changes in the resident's condition. The deficiency was identified through interviews and record reviews. The nurse's note documented the order for the CBC and UA, but there was no record of the POA being notified. When contacted by the surveyor, the POA confirmed that they were not informed about the CBC and only learned about the UA after the fact. The Assistant Director of Nursing (ADON) was unable to provide any information regarding the notification to the POA, confirming the lapse in communication and adherence to the facility's policy.
Failure to Monitor and Care Plan for Resident's Fracture and Toe Injury
Penalty
Summary
The facility failed to ensure quality care for a resident who sustained a fracture of the left forearm after hitting her elbow on the headboard of the bed. The facility did not consistently monitor the resident's left arm and did not implement a care plan regarding the fracture. Additionally, the resident had a concern with the right middle toe, which was documented as being purple and painful, but there was no monitoring of this toe. The resident's diagnoses included Alzheimer's disease, depression, anxiety disorder, and dementia, with a BIMS score indicating severe impairment. The incident began when the resident hurt her elbow while flailing her arms during a catheterization attempt. Despite the resident's complaints of pain and visible symptoms such as swelling and discoloration, the facility's response was limited to administering Tylenol and applying ice. The resident's care plan was not updated to reflect the new injury, and there was no consistent monitoring of the left arm's condition or the right middle toe. The facility's 24-hour sheets from the relevant period did not document any monitoring of these issues. The resident's condition was noted by various staff members, including LPNs, RNs, and the DON, but no comprehensive care plan was developed. The resident was eventually discharged to the hospital, where the emergency department noted old bruising and swelling of the left forearm. The facility's failure to revise the care plan and consistently monitor the resident's injuries was confirmed through interviews with the RN/ADON and the physician, who indicated that the resident had refused some interventions but was still using the injured arm to propel her wheelchair.
Failure to Provide Timely Therapy Services
Penalty
Summary
The facility did not ensure therapy services were provided in a timely manner for a resident (R2) who was readmitted to the facility. R2 had physician orders for evaluation and treatment by speech, physical, and occupational therapy, but these evaluations were not conducted. The facility's Rehabilitation Services Screening Policy and Procedure mandates that on-demand screens should be completed the same day the request is received or no later than 48 hours during regular therapy business hours. However, R2 was not evaluated or screened for therapy services as required by the physician's orders and the facility's policy. R2 was admitted with multiple diagnoses, including Hypertensive Heart Disease, Type 2 Diabetes Mellitus, Anemia, Chronic Atrial Fibrillation, and Vascular Dementia. Upon readmission from the hospital, R2's condition had declined, requiring increased assistance for daily activities. Despite this, the facility failed to conduct the necessary therapy evaluations. The surveyor noted that R2's comprehensive care plan included interventions for therapy evaluation and treatment, but these were not followed. The surveyor found that R2 had a significant decline in bed mobility and required more assistance after returning from the hospital. The facility's policy also required quarterly screenings for therapy needs, which were not conducted for R2. The Director of Nursing and the Nursing Home Administrator acknowledged the oversight but did not provide further information or documentation to show that the required evaluations had been completed. This failure to follow physician orders and facility policy resulted in a deficiency in providing timely therapy services to R2.
Failure to Inspect and Maintain Bed Frames and Rails
Penalty
Summary
The facility failed to ensure that bed frames and bed rails were inspected and maintained according to the Manufacturer's Instructions for Use (MIFU), which posed a risk of bed malfunction or resident injury. This deficiency was identified for four residents, and it had the potential to affect all 94 residents using beds in the facility. The facility's policy required regular inspections of bed frames, mattresses, and bed rails to identify and avoid areas of possible entrapment, but these inspections were not documented as required. The Maintenance Director was responsible for keeping records of bed inspections and maintenance, but during interviews, it was revealed that there was no documentation of bed rail inspections. The Maintenance Director admitted to only inspecting unoccupied beds and not documenting inspections in the TELS system for occupied beds. This lack of documentation and inspection of occupied beds was a significant oversight, as the facility's policy and the manufacturer's instructions required thorough and regular inspections. The manufacturer's instructions for the Joerns Bed Frames UltraCare XT and EasyCare Bed Platform Model ECS specified monthly inspections for loose bolts, nuts, pins, and other retaining hardware, as well as visual inspections for any damage. However, these inspections were not conducted or documented as required, leading to the deficiency. The Maintenance Director's failure to follow the established maintenance and inspection schedule contributed to the facility's non-compliance with safety standards.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to their policy and procedures, as observed during a survey. Specifically, two out of four medication carts and one out of three medication rooms were found to have medications that were either expired or lacked proper labeling. Medications such as ophthalmic and liquid medications were found without open dates, and several expired medications were not removed from stock. This included expired cranberry supplements, acetaminophen suppositories, calcium supplements, and other medications found in the first-floor medication room. Additionally, the surveyor observed that the first-floor medication cart contained open medications without listed open dates, including eye drops and a nystatin suspension bottle. The second-floor medication cart also had similar issues, with open eye drops and other liquid medications lacking open dates. Furthermore, the second-floor cart was noted to be unclean, with medication bottles unbagged and stuck to the drawer with a sticky substance. These observations were shared with the Nursing Home Administrator, but no additional information regarding the facility's Medication Storage policy was provided at that time.
Failure to Permit Resident's Return After Therapeutic Leave
Penalty
Summary
The facility did not ensure that a resident who went out on therapeutic leave was able to return to the facility, as required by their written policy. The resident, who was cognitively intact and had a BIMS score of 15, was initially admitted to the facility and later switched to Medicaid as the primary payor source. Despite having an active discharge plan, the resident expressed a desire to stay at the facility until her husband found a new apartment for them. The facility's social services and business office manager communicated with the resident and her husband about the potential for private pay if Medicaid authorization was not obtained, and the resident agreed to stay at the facility under these conditions. However, the resident went out on a therapeutic leave with her husband and did not return as planned, leading to multiple attempts by the facility to arrange her return, which were unsuccessful due to lack of communication from the resident and her husband. The facility ultimately decided not to allow the resident to return after she failed to come back by a specified date and time, as directed by the Corporate Vice President of Success. The facility did not offer a bed hold to the resident and considered her absence as a self-discharge, despite the lack of a formal discharge plan and the resident's unstable housing situation. The facility's administrator acknowledged the absence of a policy regarding bed hold or therapeutic leave and admitted that the situation was not handled with proper notice or consideration of the resident's circumstances.
Failure to Attempt Alternatives and Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that alternatives to bed rails were attempted before their use and did not document the reasons for the failure of these alternatives. This deficiency was observed in two residents, who were not informed of the risks and benefits associated with bed rail use, nor was informed consent obtained prior to installation. The facility's policy requires that alternatives be attempted and documented if they fail, but this was not adhered to in the cases reviewed. For Resident 47, the facility did not document any attempted alternatives to bed rails or why any alternatives failed. The resident, who has moderate cognitive impairment and medical conditions including hemiplegia and hemiparesis, was observed using bilateral assist bars. However, there was no evidence that the resident was adequately informed about the risks and benefits of using these bars, as required by the facility's policy. Similarly, Resident 53, who also has moderate cognitive impairment and medical conditions such as bilateral shoulder muscle wasting and type II diabetes, was found to have an assist rail on the bed without any documented attempts of alternatives or informed consent. The resident was not advised of the risks and benefits of the bed rails, and the facility did not document any failure of alternatives, contrary to their policy.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to six residents and their representatives, as required by policy and regulation. These notices should have included the reason for transfer, the place of transfer, and information on how to appeal the transfer. The deficiency was identified during a review of records, interviews, and policy examination, revealing that the facility did not adhere to its own policy of notifying residents and their representatives in writing, especially in cases of emergent hospital transfers. For Resident 47, the facility's records showed multiple hospital transfers due to medical conditions such as hemiplegia, aphasia, and congestive heart failure. However, the facility only notified an unnamed person by phone, failing to provide the required written notice. Similarly, Resident 55 experienced several hospitalizations, but the facility did not provide written notices, and the resident confirmed not receiving any documentation upon return to the facility. The survey also highlighted similar deficiencies for Residents 77, 7, 1, and 391, where the facility relied on phone notifications rather than written documentation. Interviews with staff, including the Nursing Home Administrator and Director of Nursing, confirmed the lack of written notices, with the staff under the impression that phone updates sufficed. This systemic issue affected the residents' and their representatives' ability to understand and appeal the transfers, as required by regulation.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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