Suring Health And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Suring, Wisconsin.
- Location
- 430 Manor Dr, Suring, Wisconsin 54174
- CMS Provider Number
- 525363
- Inspections on file
- 23
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Suring Health And Rehab Center during CMS and state inspections, most recent first.
Multiple residents with intact or moderately impaired cognition and significant medical conditions reported that a CNA was rough, mean, or aggressive during care, including toileting, transfers, and incontinence care, and several stated they did not want this CNA in their rooms. Family members and several CNAs, as well as an LPN unit manager, confirmed that residents complained about the CNA’s rough care and that these concerns were reported to nursing and administration. One resident directly told the administrator they felt physically and mentally abused, but there was no documented abuse investigation, no grievances, and no facility-reported incidents related to these allegations, despite a facility policy requiring immediate investigation and protection of residents when abuse is suspected or reported.
The facility failed to report multiple abuse allegations to the State Agency as required by its abuse policy. A cognitively intact resident with multiple medical conditions reported being yelled at for incontinence, forced to use a bedpan, and pinched or jabbed during care by a CNA, and stated these concerns were reported to the administrator without follow-up. Other residents with conditions such as rheumatoid arthritis, stroke, osteoarthritis, chronic kidney disease, osteomyelitis, and spastic hemiplegia, as well as a family member, reported that the same CNA was rough, aggressive, or mean with care and that they did not want this CNA in their rooms. Several CNAs and a unit manager LPN stated that residents’ concerns about rough care were reported to nursing and management, while leadership acknowledged residents refused care from the CNA but attributed this to cultural or racial issues and did not submit any abuse allegations involving this CNA to the State Agency.
The facility failed to thoroughly investigate multiple abuse allegations involving an agency CNA, despite a policy requiring immediate and comprehensive investigations of suspected abuse. A cognitively intact resident reported feeling physically and mentally abused, including being handled roughly and forced to use a bedpan, but no facility-reported incident or grievance investigation was found. Another resident’s POA contacted police with concerns about abusive practices related to therapy discontinuation and sedating medications; the facility’s investigation lacked interviews with the resident, the POA, or staff and contained only undated, general resident interviews that did not address the specific allegations. Several other residents with various medical conditions reported the same CNA was rough, aggressive, or mean with cares, did not want the CNA in their rooms, and stated concerns to staff; multiple CNAs and an LPN confirmed these reports were brought to nursing and administration, yet no corresponding investigations were documented, and leadership instead attributed refusals of care to cultural or racial issues while acknowledging investigations were not thoroughly completed.
A resident with multiple chronic conditions experienced increased pain and difficulty breathing, but staff failed to consistently assess, document, and communicate the change in condition. Orders for additional pain management and oxygen weaning were not promptly transcribed, and pain assessments and vital signs were inadequately documented. The resident's requests for relief were not effectively addressed, leading to a delayed transfer to the ER where the resident was diagnosed with sepsis, pleural effusion, and acute renal failure.
A resident suffered a head injury during a Hoyer lift transfer, but the facility delayed notifying the Hospice agency and the resident's physician. The resident experienced symptoms such as headaches and dizziness, yet the facility's communication and documentation were not timely, as confirmed by staff interviews and record reviews.
A resident was injured during a transfer using a Hoyer lift when staff failed to disconnect the catheter bag, causing the lift to fall. The resident showed signs of a head injury but was not offered hospital evaluation. The facility's investigation was incomplete, lacking documentation and staff education on safe transfers.
A resident with an indwelling Foley catheter was not placed on Enhanced Barrier Precautions (EBP) as required by the facility's policy. The resident's catheter drainage bag was observed on the floor and foot rest of a lift without a privacy cover, and CNAs provided high-contact care without wearing gowns. The Director of Nursing confirmed these actions were against the facility's infection control policies.
The facility failed to maintain sanitary conditions during food preparation, affecting all residents. A staff member did not perform proper hand hygiene and wore an inadequate beard net, leading to a resident finding hair in their food. Additionally, the staff did not check the water temperature of the sanitizing solution before testing its ppm, contrary to guidelines.
A LTC facility failed to follow diet orders and menus, affecting 13 residents on carbohydrate-controlled diets. During a lunch meal, full-sized desserts were served instead of diet-specific portions, and dinner rolls were omitted. A resident reported frequent menu changes and missing items. The Dietary Manager served desserts of the same size to all residents, and the Regional Dietary Manager confirmed the oversight.
A facility did not secure court-ordered protective placement for a resident with Alzheimer's and severely impaired cognition, who was under guardianship. The resident stayed over 60 days without the necessary paperwork due to court delays, as confirmed by the social worker. The responsibility for reviewing guardianship at admission was noted to be with another staff member.
A resident with moisture-associated skin damage was not consistently repositioned every 2-3 hours as required by their care plan. Interviews and documentation revealed that staff struggled to adhere to the repositioning schedule due to staffing challenges, leading to gaps in care and documentation.
A resident with a neck fracture was not consistently wearing a cervical collar as per physician's orders due to unclear documentation and communication among staff. The care plan lacked specific instructions, and staff were unable to locate the current order, leading to confusion about when the collar should be worn.
The facility failed to provide necessary nutritional care for two residents. One resident, at risk for weight loss, was not given a diet adjustment despite missing dentures, leading to inappropriate meal service. Another resident, with a gastrostomy tube, did not receive timely dietary review after a physician's request, delaying necessary interventions.
The facility failed to adhere to its infection control program, as observed when an RN did not perform proper hand hygiene during medication administration for two residents. The RN acknowledged the oversight, and the DON confirmed the lapse, which violated the facility's hand hygiene policy.
A resident was not offered the PCV20 vaccine as per CDC guidelines and the facility's policy. Despite having intact cognition and signing a consent form for other vaccines, the resident's medical record showed no offer of the PCV20 vaccine. The DON confirmed the oversight, acknowledging the resident should have been offered the vaccine.
Failure to Investigate and Protect Residents From Alleged Rough and Abusive Care by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from alleged physical and mental abuse and to ensure a resident environment free from abuse, as required by its Abuse, Neglect, and Exploitation policy. The policy states that an immediate investigation is warranted when suspicion or reports of abuse occur and that the facility must respond immediately to protect alleged victims and prevent further contact with the alleged perpetrator. Despite this, the facility did not initiate any investigations or documented protective measures after repeated resident and staff reports that one CNA was rough with care and that residents did not want this CNA to provide care or enter their rooms. One cognitively intact resident with multiple medical conditions, including a left humerus fracture, diabetes with neuropathy, anxiety disorder, and cellulitis, reported being physically and mentally abused since admission. This resident stated the CNA was rough with cares, yelled at the resident for incontinence, refused to get the resident out of bed to use the bathroom, used a bedpan instead, and pinched or jabbed the resident in the hip during care. The resident reported these concerns directly to the nursing home administrator within days of admission and specifically stated feeling physically and mentally abused. The resident reported that the administrator did not take the allegations seriously, suggested the resident might be anxious or depressed, and did not follow up. The medical record contained a provider note documenting the resident’s concerns about care and desire to transfer, and an administrator note referencing a care conference and the resident appearing anxious and tearful, but no documentation of an abuse investigation or specific follow-up on the rough care allegations. Additional residents with varying levels of cognition and significant medical diagnoses also reported that the same CNA was rough with cares and that they did not want this CNA in their rooms. One resident and that resident’s family member reported the CNA was mean and rough with care and communication; another resident described the CNA working too fast and being rough with transfers, leading the resident to self-transfer to avoid being touched; another resident reported the CNA was aggressive during urinal assistance and pushed the urinal too hard, causing pain; and another resident stated the CNA was mean, rough, and caused fear. Multiple CNAs and a unit manager LPN confirmed that several residents complained the CNA was rough, that some residents would not allow the CNA in their rooms, and that these concerns were reported to nursing and administration. Despite these repeated reports, the administrator denied receiving reports that the CNA was rough, and there were no grievances, facility-reported incidents, or investigations completed related to these concerns, indicating the facility did not implement its abuse policy or ensure residents were protected from potential abuse.
Failure to Report Multiple Abuse Allegations to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report multiple allegations of abuse to the State Agency (SA) as required by its Abuse, Neglect, and Exploitation policy. The policy, revised 7/1/25, directs staff to report all alleged violations to the Administrator, SA, Adult Protective Services, and other required agencies within specified timeframes, including within 2 hours for allegations involving abuse or serious bodily injury and within 24 hours for other events. Despite this, allegations that one CNA was rough with care and verbally abusive were not reported to the SA as facility-reported incidents. One cognitively intact resident with a history of left humerus fracture, type 2 diabetes with neuropathy, anxiety disorder, and cellulitis reported being physically and mentally abused and yelled at for incontinence since admission. This resident stated that the CNA was rough with care, refused to get the resident out of bed to use the bathroom, forced use of a bedpan, and pinched or jabbed the resident’s hip during care, causing pain. The resident reported these concerns to the Nursing Home Administrator a few days after admission, stating feeling mentally and physically abused, but did not receive follow-up and did not believe the concerns were taken seriously. The Administrator’s progress note from a care conference documented the resident as anxious and tearful and declining therapy and medications, but did not document the specific concerns about the CNA. Additional residents with varying levels of cognition and medical conditions, including rheumatoid arthritis, history of stroke, depression, peripheral vascular disease, osteoarthritis, chronic kidney disease, osteoporosis, edema, osteomyelitis of vertebra, severe septic shock, cerebral infarction, and spastic hemiplegia, reported that the same CNA was rough, aggressive, or mean with care and that they did not want this CNA in their rooms. Some residents described rough transfers, aggressive assistance with a urinal that caused pain, and fear of the CNA. Family members and multiple CNAs reported that residents had complained about the CNA being rough and short-tempered, and that there was a list of residents who would not allow the CNA in their rooms. A unit manager LPN reported these concerns to the DON. The Nursing Home Administrator, DON, and unit manager acknowledged that several residents did not want the CNA to provide care but attributed this to cultural and racial differences and denied receiving reports that the CNA was rough with care. No allegations of abuse related to this CNA were reported to the SA, despite the facility’s policy requiring such reporting.
Failure to Investigate Multiple Abuse Allegations Against Agency CNA
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate multiple allegations of abuse, neglect, or rough care by one agency CNA toward several residents, despite its Abuse, Neglect, and Exploitation policy requiring immediate and comprehensive investigations. The policy directs the facility to initiate an immediate investigation when there is suspicion or reports of abuse, to identify and interview all involved persons, and to provide complete documentation. Surveyors found that for six residents, the facility either did not initiate an investigation at all or conducted incomplete investigations that lacked required interviews and documentation. One cognitively intact resident with a history of left humerus fracture, diabetes with neuropathy, anxiety disorder, and cellulitis reported feeling physically and mentally abused by a specific CNA. This resident stated the CNA was rough with cares, refused to get the resident out of bed to use the bathroom, forced use of a bedpan, and pinched or jabbed the resident’s hip during care. The resident reported these concerns directly to the NHA a few days after admission and specifically stated feeling physically and mentally abused. The NHA’s progress note from a care conference documented anxiety and tearfulness and offered telehealth therapy and medication, but did not document the specific abuse concerns or any abuse investigation. Review of facility-reported incidents (FRIs) and grievances showed no investigation related to this resident’s abuse allegation. Another resident with severely impaired cognition and an activated POA for healthcare was the subject of an abuse allegation reported by the POA to the local police, who then notified the facility. The POA alleged abusive practices, including discontinuation of therapy and administration of medication to sedate the resident. The facility submitted an FRI and initiated an investigation; however, the investigation lacked interviews with the resident, the POA, or other residents and staff. The NHA later stated that resident interviews had been completed but could not initially locate them, and confirmed that staff interviews were not done. When the interviews were produced, they were undated and contained only general questions that did not address the specific allegations of overmedication and discontinuation of therapy. Additional residents with varying levels of cognitive function and medical conditions, including rheumatoid arthritis, stroke history, osteoarthritis, chronic kidney disease, osteoporosis, osteomyelitis of vertebra, severe septic shock, cerebral infarction, and spastic hemiplegia, reported that the same CNA was rough, aggressive, or mean with cares. One resident and that resident’s family reported the CNA was rough and that the resident did not want the CNA in the room; another resident reported the CNA worked too fast and was rough with transfers, leading the resident to self-transfer to avoid being touched; another resident reported the CNA pushed a urinal too hard into the resident’s testicles; and another resident reported being fearful of the CNA and not wanting the CNA in the room. These concerns were reportedly communicated multiple times to unidentified CNAs, nurses, and administration. Staff CNAs and a unit manager LPN confirmed that several residents had reported the CNA was rough with cares and that there was a list of residents who did not allow the CNA in their rooms, and that these concerns were reported to nursing and management. Despite this, review of FRIs and grievances revealed no investigations for these residents’ allegations, and the NHA, DON, and unit manager attributed residents’ refusals of care from the CNA to cultural and racial differences, while also confirming that the facility did not thoroughly investigate the allegations of rough care and abuse.
Failure to Recognize and Respond to Change in Condition and Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice, specifically related to pain management, recognition of a change in condition, and timely action. The resident, who had diagnoses including heart failure, diabetes, anxiety, and lymphedema, experienced increased pain and difficulty breathing. Despite complaints and observable distress, staff did not consistently assess, document, or communicate the resident's changing condition to the appropriate medical providers in a timely manner. Orders from a nurse practitioner for additional pain management and oxygen weaning were not transcribed into the medical record until many hours after being received, and there was a lack of thorough documentation regarding the resident's assessments and interventions throughout the day. Multiple staff interviews and record reviews revealed that the resident exhibited significant pain and respiratory distress throughout the day, including crying out during care and expressing ongoing discomfort. Certified nursing assistants and nurses noted the resident's unusual pain and lethargy, but there were gaps in communication and follow-up. Pain assessments were not consistently performed or documented, and vital signs were not always recorded. The resident's requests for pain relief and reports of difficulty breathing were not adequately addressed, and there was a delay in notifying the nurse practitioner or physician about the resident's deteriorating condition. The resident ultimately requested to be sent to the emergency room, where they were diagnosed with sepsis, right pleural effusion, and acute renal failure, and subsequently admitted to the intensive care unit. The facility's failure to recognize and act upon the resident's change in condition, complete thorough assessments, and provide timely care resulted in serious harm. Staff did not follow the facility's policies on pain management and notification of changes, nor did they adhere to the nursing process as required by professional standards. The lack of timely transcription of orders, incomplete documentation, and insufficient communication among staff contributed to the deficient practice.
Removal Plan
- Complete head-to-toe assessment for all in-house residents.
- Implement eInteract Point Click Care (PCC) Evaluation for Change in Condition and use of internet tools and resources.
- Review in-house residents in Interdisciplinary Team (IDT) meetings for completion, documentation, and identification of a change in condition, assessments (including vital signs), and provider notification.
- Educate staff on the facility's policies regarding notification, pain management, identifying a change in condition, and transcription and documentation of orders.
- Implement audits and review progress notes for change of condition response.
Delayed Notification After Resident Injury
Penalty
Summary
The facility failed to ensure timely notifications following a fall with injury for a resident who was injured during a Hoyer lift transfer. The incident occurred when the lift tipped over, causing a metal bar to strike the resident in the forehead. Despite the severity of the incident, the facility did not notify the resident's Hospice agency until five days later and the resident's physician until seven days after the incident. This delay in communication is contrary to the facility's policy, which requires immediate notification of the resident's practitioner in the event of an incident or accident. The resident involved had a medical history that included hemiplegia, type 2 diabetes, and a history of transient ischemic attack and stroke. Following the incident, the resident exhibited symptoms such as headaches, vomiting, dizziness, and double vision, along with a noticeable indent and bruising on the forehead. Despite these symptoms, the facility's documentation and communication with relevant medical personnel were delayed, as confirmed by interviews with the Hospice Registered Nurse, Director of Nursing, and the resident's physician. The physician indicated an expectation for immediate notification and monitoring of the resident's condition, which was not met by the facility.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident environment free from accident hazards, leading to an incident involving a resident (R1) during a transfer from bed to Broda chair using a Hoyer lift. On the day of the incident, staff did not disconnect R1's catheter bag from the bed, causing resistance that led to the Hoyer lift falling and striking R1 on the head. This incident resulted in R1 exhibiting signs of a head injury, including confusion, dizziness, and headaches, but R1 was not offered a medical evaluation at the hospital. The facility's investigation into the incident was incomplete, lacking physical assessments of R1 following the incident, statements from R1's roommate or other residents, and documentation of staff education on Hoyer lift transfers. Interviews with staff revealed that R1 had a dent on the forehead and experienced ongoing headaches and visual disturbances until R1's passing. Despite these symptoms, the facility did not document a thorough assessment or provide adequate follow-up care. Additionally, the facility did not promptly notify R1's Hospice agency or primary physician about the incident. The Director of Nursing confirmed that staff and resident interviews were not conducted, and only verbal education was provided to a limited number of staff involved in the incident. The lack of comprehensive investigation and documentation highlights a deficiency in the facility's accident and supervision policies.
Inadequate Infection Control for Resident with Foley Catheter
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with an indwelling Foley catheter. The resident, who had intact cognition and was their own decision maker, was readmitted to the facility with a Foley catheter after treatment for a urinary tract infection and urosepsis. Despite the facility's policy requiring Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, the resident's medical record did not contain an order for EBP, and no sign or storage bin with gowns and gloves was observed outside the resident's room. During an observation, two Certified Nursing Assistants (CNAs) provided high-contact care to the resident without wearing gowns, as required by the facility's EBP policy. Additionally, the resident's catheter drainage bag was placed on the floor and the foot rest of a lift without a privacy cover, contrary to the facility's catheter care policy. The Director of Nursing confirmed that the resident should have been on EBP and that the catheter bag should not have been placed on the floor or foot rest, and should have been covered at all times.
Sanitation and Hygiene Deficiencies in Food Preparation
Penalty
Summary
The facility failed to ensure food was prepared in a sanitary manner, potentially affecting all 34 residents. During an observation, a staff member did not perform proper hand hygiene while plating food. The staff member was seen adjusting their beard net, touching the stove, and continuing to plate food without washing their hands. Additionally, the beard net worn by the staff member did not adequately cover all facial hair, leaving the mustache and upper cheek area exposed. This lack of proper hygiene was linked to a resident's complaint of finding hair in their food, specifically in a pea salad. Furthermore, the facility did not adhere to proper procedures for preparing sanitizing solutions. The staff member responsible for sanitizing countertops did not check the water temperature of the sanitizing solution before testing its parts per million (ppm), as required by the facility's guidelines and the instructions on the test strip package. This oversight was confirmed during an interview with the staff member, who acknowledged the failure to check or document the water temperature, despite a sign in the kitchen indicating the correct procedure.
Failure to Follow Diet Orders and Menu in LTC Facility
Penalty
Summary
The facility failed to adhere to diet orders and menus, compromising the nutritional needs of 13 residents who were on carbohydrate-controlled diets. During a lunch meal, the facility served full-sized desserts instead of the prescribed diet desserts or reduced servings for residents with specific dietary requirements. The facility's Therapeutic Diet Orders document mandates that residents receive food in the appropriate form and nutritive content as prescribed by a physician or assessed by the Interdisciplinary Team. However, the facility did not comply with these orders, as observed during the meal service. Additionally, the facility did not serve all menu items as planned, such as dinner rolls, which were omitted from the lunch service. A resident expressed concerns about frequent menu changes without prior notice and not receiving all listed meal items. The Dietary Manager was observed serving desserts of the same size to all residents, regardless of their dietary restrictions, and was unaware of the missing dinner rolls. The Regional Dietary Manager confirmed the oversight and acknowledged the failure to provide the correct serving sizes for residents on restricted diets.
Failure to Obtain Court-Ordered Protective Placement for Resident
Penalty
Summary
The facility failed to ensure court-ordered protective placement for a resident with Alzheimer's disease, who had severely impaired cognition and was under guardianship. The resident was admitted to the facility and had been residing there for over 60 days without the necessary protective placement paperwork. The social worker confirmed that the resident had a guardian but acknowledged that protective placement was not pursued due to court backlogs. The social worker also indicated that the responsibility for reviewing guardianship at the time of admission fell to another admissions staff member.
Failure to Consistently Reposition Resident with Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and promote healing of pressure injuries for a resident, identified as R5, who had moisture-associated skin damage (MASD) on the left buttock and right sacral area. R5's care plan required repositioning every 2-3 hours, but this intervention was not consistently implemented. Interviews with R5 and R5's spouse revealed that repositioning was not occurring as prescribed, and the spouse expressed concerns about staff availability to perform these tasks. The medical record review confirmed that the repositioning task was not documented as completed on several occasions. The facility's staff, including CNAs and nursing staff, acknowledged challenges in adhering to the repositioning schedule due to staffing constraints. The Director of Nursing (DON) expected CNAs to document repositioning activities, but the surveyor found gaps in documentation, indicating that repositioning was not consistently performed. The deficiency was further highlighted by the Hospice RN's observations and discussions with the facility's charge nurse, which confirmed discrepancies in the care provided to R5.
Failure to Implement Physician's Order for Cervical Collar
Penalty
Summary
The facility failed to ensure that a cervical collar was implemented per the physician's order for a resident who was admitted following a neck fracture. The resident, who had intact cognition and was responsible for their healthcare decisions, was observed without the cervical collar on multiple occasions. The care plan did not specify when the collar should be worn or if it could be removed, and the Treatment Administration Record did not include orders for wearing the collar. A consultation report recommended wearing the collar at all times except during hygiene, but this was not reflected in the resident's current orders. Staff interviews revealed confusion regarding the order for the cervical collar. A CNA and an RN both stated that the collar should be worn at all times, but the RN could not find the order. The Director of Nursing also could not locate the current order and later indicated that a discontinuation order was mistakenly applied to the wrong resident. This lack of clear documentation and communication led to the resident not consistently wearing the cervical collar as required for their condition.
Failure to Provide Adequate Nutritional Care for Residents
Penalty
Summary
The facility failed to provide necessary treatment and services related to nutrition for two residents, R13 and R17. R13, who was at risk for weight loss and had a diagnosis of moderate protein calorie malnutrition, experienced a further decline in weight due to missing dentures, which were not reported to the dietary manager or nursing home administrator. Despite R13's inability to chew properly without dentures, the dietary staff was not informed to adjust R13's diet accordingly. This oversight led to R13 being served inappropriate meals, such as cut-up chicken, which R13 could not eat, resulting in continued weight loss and poor appetite. For R17, the facility did not contact the registered dietitian as requested by the physician to review R17's tube feeding after a new medication was started. R17, who had a gastrostomy tube and was diagnosed with throat cancer, required dietary adjustments due to low sodium and elevated potassium levels. However, the registered dietitian was not notified until eight days after the physician's request, delaying necessary dietary interventions. This lack of timely communication and action contributed to the deficiency in providing adequate nutritional care for R17.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during medication administration for two residents, R12 and R29. On September 4, 2024, a surveyor observed Registered Nurse (RN)-F preparing medication for R12 without performing hand hygiene before administering the medication. Similarly, RN-F did not perform hand hygiene before, during, or after preparing and administering medication to R29. These actions were in direct violation of the facility's Hand Hygiene policy, which mandates hand hygiene before preparing or handling medication. During interviews, RN-F acknowledged the failure to perform hand hygiene as required by the facility's policy. The Director of Nursing (DON)-B also confirmed that hand hygiene was not completed during the medication pass and stated that the expectation is for staff to perform hand hygiene before medication preparation, after preparation, and after distribution. This deficiency highlights a lapse in adherence to established infection control protocols, potentially increasing the risk of disease transmission among residents and staff.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a pneumococcal vaccination to a resident, identified as R10, in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and the facility's own policy. The policy, implemented in June 2023, mandates that residents be offered immunization against pneumococcal disease unless medically contraindicated or previously immunized. R10, who was admitted with diagnoses including diabetes and cerebral infarction, had a Minimum Data Set (MDS) assessment indicating intact cognition. Despite having signed a consent form for influenza and COVID-19 vaccines, which also documented previous pneumococcal vaccinations (PPSV23 in 2012 and PCV13 in 2015), there was no record of R10 being offered the PCV20 vaccine. During the survey conducted from September 3 to September 5, 2024, it was discovered that the line for the PCV15 or PCV20 vaccine date on R10's consent form was blank, and the medical record lacked any indication that the PCV20 vaccine was offered. The Director of Nursing (DON) confirmed in an interview that R10 was not offered the PCV20 vaccine, acknowledging that it should have been offered at the time R10 signed the consent form for the other vaccines. This oversight represents a failure to adhere to both CDC guidelines and the facility's vaccination 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
