The Pines Post Acute And Memory Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Clintonville, Wisconsin.
- Location
- 1625 E Main St, Clintonville, Wisconsin 54929
- CMS Provider Number
- 525497
- Inspections on file
- 19
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at The Pines Post Acute And Memory Care during CMS and state inspections, most recent first.
A medication cart was found unlocked and unattended for 10 minutes during medication administration, contrary to facility policy requiring carts to be locked or attended by authorized staff. An RN acknowledged leaving the cart unsecured, and the DON confirmed that carts should always be locked when unattended.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, as observed by surveyors.
A resident with left-sided paralysis and intact cognition did not have consistent access to a call light within reach and was not provided with hearing aids as indicated in their MDS assessment. The care plan addressed fall risk and call light use but failed to include interventions for hearing needs. Staff and the DON confirmed these deficiencies, and the facility lacked a specific call light policy.
Two residents with severely impaired cognition and healthcare Guardians were transferred or discharged without receiving required written transfer or bed hold notices, and the Ombudsman was not notified as mandated by facility policy. Staff confirmed that these notifications were missed for both hospital transfers and discharges.
A resident with dementia, diabetes, and unsteadiness experienced a fall with injury while attempting to ambulate independently. After therapy staff recommended one-person assistance with a gait belt for all transfers and ambulation, the care plan was not updated, and nursing staff continued to believe the resident was independent. This lack of care plan revision and communication led to a deficiency in accident hazard prevention and supervision.
A resident did not receive enough food and fluids to maintain their health, as observed and documented by surveyors.
Staff did not consistently follow care plans for two high-risk residents, failing to ensure bed and chair alarms were in place and not adhering to specific safety instructions such as keeping a recliner footrest down. These lapses led to multiple falls, including one resulting in a hip fracture and another causing a reopened head wound, despite facility policy requiring regular checks of fall prevention interventions.
The facility did not ensure that a contracted CNA's background check documentation was available and complete, as required by state regulations. The CNA's agency withheld background check documents from the facility, citing privacy concerns, and did not follow state requirements for reviewing certain convictions. The necessary documents were only provided to the surveyor upon direct request, indicating a breakdown in the facility's process for screening agency staff.
A resident with severe cognitive impairment and a history of tearing incontinence briefs was physically restrained by a CNA, who tied the resident's nightgown sleeves with the resident's arms inside and tucked a blanket under the mattress, restricting movement and access to the call light. The restraint was discovered by an LPN during a routine check, and staff interviews confirmed the CNA's actions were not in accordance with facility policy.
The facility did not ensure a required four-year background check was completed for an agency CNA, as the only available documentation was last reviewed in 2019, despite the CNA having worked in the facility within the past three months. This was not in accordance with the facility's policy for background check frequency.
The facility failed to maintain proper temperature for a medication refrigerator and did not ensure medications for 11 residents were labeled and dated appropriately. Observations revealed temperatures above the acceptable range and multiple instances of improperly labeled or expired medications.
The facility failed to ensure safe food handling practices, as evidenced by incorrect food cooling procedures documented on six occasions. The Dietary Manager and Nursing Home Administrator confirmed that the facility follows the Wisconsin Food Code, but the cooling logs showed multiple instances where the guidelines were not followed, and corrective actions were not taken.
A resident with a history of sepsis due to a UTI did not receive proper catheter care, as a CNA cleaned the catheter tubing incorrectly, increasing the risk of infection. The DON confirmed the correct procedure was not followed.
The facility failed to provide accurate pharmaceutical services for two residents. An LPN did not follow proper procedures for administering inhalers and crushed an enteric-coated tablet, which should not be crushed. Additionally, a resident was given an unprescribed supplement.
A facility failed to maintain proper infection control during wound care for a resident on Enhanced Barrier Precautions. An LPN did not wear the required gown and did not perform appropriate hand hygiene, instead using two sets of gloves to avoid handwashing. The resident had multiple diagnoses requiring careful wound care, but the LPN's actions did not comply with the facility's infection control policy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the Memory Lane unit was observed by a surveyor to be unlocked and unattended for 10 minutes during medication administration. The facility's policy requires that medication carts be locked or attended by authorized personnel at all times. During the observation, a registered nurse (RN) returned to the cart and confirmed that it had been left unlocked and unattended, stating that it was an accident and not their usual practice. The Director of Nursing also confirmed that medication carts should be locked when unattended. This incident had the potential to affect more than 4 of the 44 residents in the facility.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Failure to Ensure Call Light Accessibility and Hearing Aid Provision
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis following a stroke, as well as other medical conditions such as anxiety, chronic pain, asthma, and neuromuscular bladder dysfunction, was found to have deficiencies in care related to the accommodation of their needs and preferences. The resident's care plan identified a risk for falls due to left-sided weakness and included interventions to ensure the call light was within reach. However, on multiple occasions, the call light was observed to be placed on the resident's left side, which was affected by paralysis, making it inaccessible. The resident reported that staff sometimes intentionally placed the call light out of reach, requiring the use of a reacher to access needed items. Staff confirmed the call light was not within reach and only corrected its placement after being notified by the surveyor. Additionally, the resident's Minimum Data Set (MDS) assessment indicated the use of hearing aids, but the care plan did not address hearing or hearing aids. The resident was observed without hearing aids and stated that staff did not assist with putting them in, requiring the resident to request this assistance. The Director of Nursing confirmed the absence of a care plan for hearing aids and acknowledged that the call light should have been within reach due to the resident's limited mobility. The facility did not have a specific call light policy, relying instead on the standard of care.
Failure to Provide Required Transfer, Bed Hold, and Ombudsman Notifications
Penalty
Summary
The facility failed to provide required written transfer and/or bed hold notices, as well as Ombudsman notifications, for two residents who were transferred to the hospital or discharged. One resident, who had severely impaired cognition and a healthcare Guardian, was transferred to the hospital on three separate occasions for medical issues including a brain bleed, complicated UTI, and pneumonia. On each occasion, neither the resident nor the Guardian received a written transfer or bed hold notice, and there was no documentation that the Ombudsman was notified of the transfers or the final discharge. Staff interviews confirmed that these notifications were not completed as required by facility policy. Another resident, also with severely impaired cognition and a healthcare Guardian, was discharged to an assisted living facility without documentation that the Ombudsman was notified of the discharge. Staff interviews further verified that Ombudsman notifications for transfers and discharges were missed during the relevant period. The facility's policy requires written notification to residents or their representatives regarding bed hold rights and transfer/discharge, as well as notification to the Ombudsman, but these steps were not followed for the residents in question.
Failure to Update Care Plan After Resident Fall and Therapy Recommendations
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was as free from accident hazards as possible and did not provide adequate supervision to prevent accidents for a resident with multiple risk factors. The resident, who had diagnoses including dementia, diabetes mellitus type 2, unsteadiness on feet, long-term use of anticoagulants, and general weakness, experienced a fall with injury. The resident had severely impaired cognition and an activated Power of Attorney for Healthcare. On the day of the fall, the resident attempted to ambulate independently to the restroom, using a walker and wearing gripper socks, but fell and sustained a head injury. Staff responded after hearing the resident call for help and observed the walker on the resident's chest. Following the fall, the facility referred the resident for physical and occupational therapy, and therapy staff determined that the resident required assistance of one staff member with a gait belt for all transfers and ambulation. However, the resident's care plan was not updated to reflect these new recommendations, and nursing and CNA staff continued to believe the resident was independent with transfers and ambulation unless assistance was requested. Communication of the therapy recommendations occurred during a morning meeting, but the care plan was not revised, and staff relied on outdated information. This failure to update the care plan and ensure all staff were aware of the resident's current needs contributed to the deficiency.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The report specifically notes the lack of provision of adequate food and fluids necessary for the resident's health maintenance.
Failure to Implement Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
Staff failed to implement and maintain required fall prevention interventions for two residents identified as being at high risk for falls. One resident with Parkinson's disease and moderate cognitive impairment had a care plan specifying the use of bed and chair alarms to alert staff of self-ambulation and a restriction against raising the footrest of the recliner. Despite these interventions, the resident was found on the floor with a reopened suture above the right eye after staff did not activate the bed alarm when assisting the resident to bed. Additionally, staff were observed raising the recliner footrest, contrary to the care plan instructions, and some staff were unaware of the need for a bed alarm. Another resident with dementia, multiple sclerosis, and a history of falls had a care plan requiring bed and chair alarms and two-person pivot transfers with a gait belt and walker. The resident experienced multiple falls when staff failed to ensure the presence of required alarms. On one occasion, the resident fell and sustained a hip fracture after the chair alarm was not in place, and the sensor pad was found on the floor. Staff interviews revealed a lack of awareness regarding the need for chair alarms, and the resident was last seen in a wheelchair before self-transferring and falling. The facility's own Falls Program policy required staff to check for correct application of care-planned interventions at the beginning of every shift, including alarms and other safety devices. Despite this policy, staff did not consistently follow care plan interventions for fall prevention, resulting in multiple falls and injuries for both residents.
Failure to Ensure Proper Background Checks for Agency CNA
Penalty
Summary
The facility failed to implement and enforce written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation of resident property, as evidenced by incomplete caregiver background checks for one of eight staff reviewed. Specifically, a contracted CNA's background check documentation was not available in the facility's records, and the facility was unable to provide the required Wisconsin DOJ criminal background check letter or IBIS letter for this staff member. The Human Resource Manager indicated that the staffing agency no longer provided these documents to the facility due to privacy concerns and a previous data breach. Further investigation revealed that the agency employing the CNA did not follow the Wisconsin Caregiver Program requirements regarding offenses affecting caregiver eligibility, particularly for convictions of disorderly conduct. The agency manager was unaware of the specific state requirements and relied on the agency's own hiring standards, which did not include a detailed review of certain convictions. The necessary background check documents were only provided to the surveyor after direct request, highlighting a lapse in the facility's process for ensuring all staff, including agency staff, are properly screened according to state regulations.
Resident Physically Restrained by CNA Using Nightgown and Blanket
Penalty
Summary
A resident with Alzheimer's disease, hemiplegia, hemiparesis, major depressive disorder, and aphasia, who required total assistance for lower torso care and had a history of tearing apart incontinence briefs, was physically restrained by a Certified Nursing Assistant (CNA) during a PM shift. The CNA tied the sleeves of the resident's nightgown closed with the resident's arms inside and tucked a blanket across the resident's lap and under both sides of the mattress. This action was taken after the resident repeatedly attempted to remove their brief. As a result, the resident was unable to access their hands, move freely in bed, or reach the call light. The restraint was discovered by a Licensed Practical Nurse (LPN) during a routine check on the next shift, approximately two and a half hours later. The LPN found the resident with their arms inside the nightgown and a blanket tucked under the mattress, immediately untied the sleeves, and provided care. The resident was assessed for physical and psychological harm, with no new injuries noted, although bruising was observed on the tops of the resident's hands, which was determined not to be new. The resident, when interviewed, was only able to provide limited responses but indicated feeling fine and not having been hurt. Staff interviews and record reviews confirmed that the CNA had restrained the resident to prevent them from tearing at their brief and throwing items. The facility's policy prohibits the use of physical restraints for discipline or convenience and defines a physical restraint as any method that restricts freedom of movement or normal access to one's body. The CNA acknowledged in a statement that tying the sleeves was a poor decision, and the facility determined that the resident had been restrained during the last rounds of the PM shift.
Removal Plan
- Initiated physical and psychosocial monitoring for R1.
- Completed skin assessment for other cognitively impaired residents.
- Notified CNA-C's staffing agency and did not allow CNA-C to return to the facility.
- Educated facility and agency staff on the facility's abuse and restraint policies.
Failure to Complete Timely Background Check for Agency CNA
Penalty
Summary
The facility failed to implement its own policies and procedures regarding the prevention of abuse, neglect, and theft by not ensuring a timely and thorough background check for one Certified Nursing Assistant (CNA-H) out of eight sampled staff. According to the facility's Pre-Employment Investigations policy, background checks, including a Background Information Disclosure (BID) form, Department of Justice (DOJ) report, and Integrated Background Information System (IBIS) letter, are required every four years for all staff, including agency staff. Surveyor review revealed that CNA-H, an agency CNA who began working at the facility on 7/1/23, only had background check documentation dated 8/14/19, which was last completed and reviewed by the agency. The Nursing Home Administrator confirmed that CNA-H had worked in the facility within the last three months and that no updated background check had been obtained since 2019, despite the facility's policy requiring such checks every four years.
Improper Medication Storage and Labeling
Penalty
Summary
The facility did not ensure that one of the two refrigerators in the medication storage room, which contained vaccines and insulin, maintained a temperature between 36 and 46 degrees Fahrenheit. Observations revealed that the refrigerator's temperature was consistently above the acceptable range, with readings of 52 and 54 degrees. The temperature logs indicated multiple instances where the temperature exceeded 46 degrees, and the logs were not filled out twice daily as required. The Director of Nursing (DON) was unaware of the correct temperature range and the frequency of temperature checks, which contributed to the deficiency in maintaining proper storage conditions for temperature-sensitive medications. Additionally, the facility failed to ensure that medications for 11 residents were labeled and dated appropriately. Observations of three medication carts revealed multiple instances of improperly labeled or expired medications, including insulin pens, inhalers, and eye drops. The Medication Tech confirmed the improper labeling and expiration of these medications. The DON and Pharmacist also confirmed that the medications should have contained open/expiration dates and resident names and should have been disposed of when beyond the open date timeframe guidelines.
Improper Food Cooling Practices
Penalty
Summary
The facility did not ensure safe food handling practices were implemented, as evidenced by incorrect food cooling procedures documented on six occasions from December 2023 to April 2024. During an initial tour of the kitchen, the Dietary Manager (DM) indicated that the facility follows the Wisconsin Food Code, which requires cooked time/temperature control for safety food to be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and then to 41 degrees Fahrenheit or less within a total of 6 hours. However, the facility's food cooling logs showed multiple instances where these guidelines were not followed, and corrective actions were not taken as required. For example, on 12/24/23, a roast was recorded with a start temperature of 191 degrees Fahrenheit, but the 2-hour cooling temperature was incorrectly logged as 201 degrees Fahrenheit, and no corrective action was noted. Similar issues were found with entries for meat sauce, lasagna, chicken noodle, and other foods, where the cooling temperatures did not meet the required standards, and corrective actions were either not documented or not taken. On 5/14/24, the Surveyor interviewed the Dietary Manager, who confirmed that cooked food should be cooled to 70 degrees Fahrenheit within 2 hours and to 41 degrees Fahrenheit within a total of 6 hours. The Surveyor reviewed the cooling log entries with the Dietary Manager, who acknowledged that kitchen staff should be re-educated on the food cooling process. The Nursing Home Administrator also confirmed that the facility uses the [NAME] Cooling Food document as their policy/procedure for cooling food and follows the Wisconsin Food Code. The review of the food cooling entries with the Nursing Home Administrator indicated that education was initiated for kitchen staff on proper cooling methods, but the deficiencies in the cooling process were evident in the logs reviewed.
Improper Catheter Care Leading to Increased Risk of UTI
Penalty
Summary
The facility did not ensure that a resident received appropriate catheter care to prevent urinary tract infections (UTIs). The resident had a history of sepsis due to a UTI and was recently prescribed an antibiotic for this condition. During an observation, a Certified Nursing Assistant (CNA) was seen cleaning the length of the Foley catheter tubing incorrectly, starting from the drainage bag and moving toward the resident, which is contrary to the facility's policy that mandates cleaning from the resident toward the drainage bag to prevent infection. The CNA admitted to not knowing the proper procedure for catheter care. The Director of Nursing (DON) confirmed that the correct procedure is to clean the catheter from the resident toward the drainage bag. The resident involved had moderately impaired cognition and an activated healthcare decision maker. The deficiency was identified during a review of the resident's medical record and an observation of the CNA's catheter care technique.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility did not provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for two residents. An LPN administered an Advair Diskus inhaler to a resident with severe cognitive impairment without offering water for rinsing and spitting as required. Additionally, the LPN crushed an enteric-coated ferrous sulfate tablet, which should not be crushed, per the medication's guidelines. The resident's medical record confirmed the necessity of these actions, and the LPN acknowledged the error during an interview. Another resident with severe cognitive impairment was administered a Breo Ellipta inhaler without being offered water to rinse and spit as required. Furthermore, the LPN provided this resident with 120 cc of Med Pass 2.0, a supplement not ordered for the resident. The resident's medical record indicated a different supplement was to be provided, and the DON confirmed that Med Pass 2.0 was not the correct supplement. These actions were observed and verified through staff interviews and record reviews.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection during the provision of wound care for a resident on Enhanced Barrier Precautions (EBP). During an observation, an LPN did not don the appropriate personal protective equipment (PPE) and did not perform appropriate hand hygiene while providing wound care to the resident. The LPN only wore two sets of gloves and did not use a gown, which is required for high-contact resident care activities under EBP guidelines. The resident had multiple diagnoses, including a methicillin-susceptible Staphylococcus aureus (MSSA) infection, a non-pressure chronic ulcer of the left calf, and local infection of the skin and subcutaneous tissue. The resident's medical record indicated the need for wound care to bilateral lower extremities, which included cleansing with mild soap and water, applying ammonium lactate to dry areas, and using ABD pads and Kerlix for weeping areas. Despite these requirements, the LPN failed to follow proper infection control procedures during the wound care process. The LPN admitted to not wearing a gown and confirmed the practice of wearing two sets of gloves to avoid performing hand hygiene between steps of the wound care process. Additionally, the LPN did not perform hand hygiene after leaving the resident's room to get more supplies and before resuming wound care. The Director of Nursing confirmed that the LPN's actions were not in accordance with the facility's infection control policy and procedure, and the LPN was subsequently educated on the correct practices.
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.
