Tudor Oaks Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskego, Wisconsin.
- Location
- S77 W12929 Mcshane Dr, Muskego, Wisconsin 53150
- CMS Provider Number
- 525279
- Inspections on file
- 27
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Tudor Oaks Health Center during CMS and state inspections, most recent first.
A resident reported being treated roughly by a CNA who was not attentive during care, leading to a substantiated abuse allegation. Although the incident was investigated and reported, there was no evidence that the facility implemented measures to prevent further abuse or ensure resident safety.
Three residents were not protected from physical and verbal abuse, including rough care by a CNA and aggressive treatment by an RN. In both cases, staff who witnessed or were informed of the abuse did not immediately intervene or report the incidents to facility leadership, resulting in delays in protecting the residents and allowing the alleged abusers to continue working.
The facility did not ensure that allegations of verbal and physical abuse involving three residents were promptly reported to the NHA or designee and to law enforcement, as required by policy. In one case, a resident reported rough care by a CNA, and in two other cases, a RN was alleged to have aggressively handled and verbally abused two residents with significant cognitive and physical impairments. These incidents were not reported to law enforcement or the state agency, and staff failed to follow proper reporting procedures.
A facility failed to investigate an allegation of physical abuse after a CNA reported that a nurse handled a resident with hemiplegia aggressively, causing visible pain. Despite a written statement and facility policy requiring immediate investigation, no inquiry was conducted because the resident did not complain and the CNA's report was considered emotionally charged by administration.
Several residents did not receive adequate supervision or assistance devices to prevent accidents, with multiple falls and a resident-to-resident altercation not thoroughly investigated. In one case, a resident with dementia and high fall risk suffered a hip fracture after staff failed to implement additional interventions or conduct a root cause analysis. Other residents experienced falls due to improper transfer techniques, lack of care plan updates, and missing or incorrectly placed safety devices. These deficiencies resulted in actual harm for one resident and the potential for more than minimal harm for others.
Surveyors found that food was not stored, prepared, or served according to professional standards, with missing temperature logs, undated food items, dirty and improperly stored scoops in bulk food bins, and a staff member preparing food without a beard guard. These deficiencies in food safety practices had the potential to affect all residents.
Surveyors identified multiple failures in the infection prevention and control program, including not tracking baseline infection rates for prevalent infections, inconsistent flushing of the eye wash station, and failure to implement Enhanced Barrier Precautions (EBP) for residents with stage 2 pressure injuries. Staff were observed providing care without proper PPE and not following hand hygiene protocols during medication administration. Additionally, a resident's catheter bag and tubing were repeatedly found resting on the floor without a privacy cover or barrier, in violation of facility policy.
Four residents were transferred to the hospital without receiving written notification of the reason for transfer, bed-hold policies, or the specific daily rate for holding their bed. Instead, staff relied on verbal consent and did not provide the required written documentation at the time of transfer, and the bed-hold forms in the medical records lacked the necessary rate information.
A resident with moderate cognitive impairment and a diagnosis of dementia, who was not approved for self-administration of medications, was left unsupervised with a cup containing seven pills by an LPN at the resident's request. Facility policy requires interdisciplinary team approval for self-administration, but this was not followed, as confirmed by observation, staff interviews, and record review.
Two residents did not have their care plans promptly updated after significant changes in their condition, including a new transfer status and the development of a stage 2 pressure injury. Although interventions were implemented, the official care plans were not revised in a timely manner to reflect these changes, as required by facility policy.
Three residents experienced deficiencies in pressure injury prevention and care, including lack of timely assessment and care plan updates for new or worsening wounds, failure to provide pressure relief while seated, and inadequate monitoring of skin integrity under a wanderguard. Nursing staff did not consistently perform or document required skin assessments, and interventions were not promptly implemented or revised in response to changes in residents' skin condition.
Three residents with diabetes and related complications did not receive or have documentation of daily diabetic foot checks as required by professional standards and the facility's own policy. Nursing staff confirmed that only weekly skin checks were performed, and daily foot checks were not part of routine practice, resulting in a deficiency related to diabetic foot care.
Three residents prescribed anticoagulants for conditions such as pulmonary embolism and atrial fibrillation were not monitored for signs and symptoms of complications, despite facility policy requiring such monitoring. Nursing staff acknowledged that monitoring was based on judgment and not consistently documented, and care plans or physician orders did not always include interventions for monitoring adverse effects.
The facility did not ensure proper collaboration and communication with hospice providers for three residents, resulting in missing hospice care plans, visit notes, and provider schedules. Staff were unclear about who was responsible for coordinating hospice care, and documentation was inconsistent or incomplete, leading to gaps in continuity of care.
A resident with severe cognitive impairment was subjected to verbal abuse by an RN during toileting care. Although a CNA promptly reported the incident to an LPN, the LPN did not immediately notify administrative staff, allowing the RN to continue working and interact with other residents for the remainder of the shift. The facility also failed to collect all relevant staff statements regarding the incident.
A resident with dementia and multiple medical conditions was subjected to alleged verbal abuse by an RN during toileting assistance. The incident was promptly reported by a CNA to an LPN, but the LPN failed to immediately notify facility leadership as required by policy, allowing the RN to continue working until the end of the shift and potentially exposing other residents to further risk.
A resident with severe cognitive impairment was subjected to alleged verbal abuse by an RN, which was overheard and reported by a CNA. The LPN on duty did not immediately report the allegation to facility leadership, allowing the RN to continue working until the end of the shift. The facility failed to collect statements from all staff present, did not update the resident's care plan to address psychosocial needs, and did not notify the resident's psychologist about expressions of distress, resulting in an incomplete investigation and lack of appropriate resident protection.
Surveyors found that daily nurse staffing postings did not accurately reflect the actual number and type of staff present for multiple days. Discrepancies included incorrect counts of RNs, LPNs, and CNAs, as well as inaccurate reporting of hours worked, due to a lack of ongoing review and updates to the postings as staffing changes occurred.
Two residents experienced falls resulting in injury due to the facility's failure to provide adequate supervision and implement consistent fall prevention interventions. One resident, with multiple medical conditions and on hospice, had five unwitnessed falls, with interventions inconsistently documented and not always in place, leading to a hip fracture. Another resident with parkinsonism fell from a wheelchair and sustained a head injury because wheelchair foot pedals were not applied during transport. In both cases, care plans were not promptly or thoroughly updated, and root cause analysis was lacking.
A facility failed to classify a resident's fall and did not follow post-fall protocols, leading to a lack of investigation and documentation. Additionally, CNAs used an incorrect transfer method for another resident, contrary to the care plan, resulting in a near-fall incident. Staff interviews revealed non-compliance with facility policies.
Failure to Implement Preventive Measures After Substantiated Abuse
Penalty
Summary
A resident alleged that a Certified Nursing Assistant (CNA) was rough while providing care, specifically when rolling the resident in bed. The resident reported that the CNA was wearing ear buds and was not listening to the resident's attempts to communicate about pain and how care should be performed. Documentation indicated that the resident was tearful after the interaction. The facility contacted local police and conducted interviews with residents and staff following the allegation. Despite substantiating the abuse allegation, the facility did not provide documentation or evidence to surveyors that measures were put in place to prevent recurrence of abuse or to ensure the safety of the resident and others. The facility's abuse policy requires immediate investigation and implementation of actions to prevent further abuse, but there was no evidence that such preventive measures were taken after the incident.
Failure to Protect Residents from Physical and Verbal Abuse
Penalty
Summary
Three residents were not protected from physical and verbal abuse as required by facility policy. In one instance, a resident receiving care from an agency CNA was treated roughly, with the CNA pulling the resident's legs apart and being rough while cleaning, despite the resident voicing pain and asking the CNA to stop. Another CNA was present during this incident but did not intervene to stop the rough treatment, only reporting the concern after the care was completed. The facility's Social Services Director and Nursing Home Administrator confirmed that the witnessing CNA was expected to intervene immediately to protect the resident but did not do so. In two separate cases, a registered nurse was alleged to have physically and verbally abused two residents with significant cognitive and physical impairments. One resident, who had severe dementia and was dependent for care, was rolled and wiped aggressively, causing distress and pain, while the nurse made inappropriate verbal remarks. The incident was witnessed by a CNA, who reported it to another nurse. However, instead of immediately escalating the report to facility leadership, the CNA and nurse left written statements under the DON's office door, who was not present at the time. This delayed the initiation of an investigation and allowed the accused nurse to continue working subsequent shifts before the allegations were addressed. The second resident, who also had significant neurological and physical impairments, was similarly treated aggressively by the same nurse. The CNA's statement described the nurse rolling the resident onto their affected side and wiping them aggressively, causing visible pain. Again, the report was not immediately brought to the attention of facility leadership, and the nurse continued to work. In both cases, the facility failed to ensure immediate protection of the residents from further potential abuse, as required by their own policies.
Failure to Report Alleged Abuse and Neglect to Authorities
Penalty
Summary
The facility failed to ensure that allegations of potential verbal and physical abuse involving three residents were reported to the Nursing Home Administrator (NHA) or designee and to law enforcement as required by facility policy and regulation. In one instance, a resident complained that a Certified Nursing Assistant (CNA) was rough during care, including pulling the resident's legs apart and being rough while cleaning, which caused the resident to express pain and distress. Although the incident was reported internally and the CNA was removed pending investigation, law enforcement was not contacted, contrary to policy requirements for reporting suspected abuse. In two additional cases, a Registered Nurse (RN) was alleged to have verbally and physically abused two residents on the same night. One resident, who had severe cognitive impairment and was dependent for care, was reportedly rolled aggressively and wiped in a manner described as aggressive, with the RN making an inappropriate statement to the resident. The incident was not immediately reported to the NHA, and law enforcement was not notified. The second resident, who had hemiplegia, hemiparesis, and dementia, was also allegedly rolled and wiped aggressively by the same RN, causing visible signs of pain. This allegation was not reported to the state agency or law enforcement, and there was no documented investigation for this resident. Staff interviews and record reviews revealed that statements regarding these incidents were left under the Director of Nursing's (DON) office door while the DON was absent, and there was confusion among staff about reporting procedures. The NHA and Director of Social Services only became aware of the incidents after being informed by another CNA during an unrelated meeting. The facility's failure to report these allegations to the appropriate authorities within the required timeframes constitutes a deficiency in following abuse reporting protocols.
Failure to Investigate Allegation of Physical Abuse
Penalty
Summary
The facility failed to investigate an allegation of physical abuse involving one resident, despite having a policy that requires immediate investigation of all reports or suspicions of abuse, neglect, or exploitation. According to the facility's policy, an investigation should be initiated when any such allegation is reported, including identifying responsible staff, interviewing all involved parties, and thoroughly documenting the process. In this case, a Certified Nursing Assistant (CNA) reported that a Registered Nurse (RN) rolled a resident aggressively onto his affected side and wiped him in a manner that caused visible pain. The CNA documented this incident in a written statement and submitted it to the Director of Nursing. However, there was no evidence that an investigation was initiated for this allegation. The resident involved had significant medical conditions, including hemiplegia and hemiparesis following a stroke, heart failure, diabetes mellitus, and dementia. Despite the CNA's detailed statement and the facility's policy, both the Director of Social Services and the Nursing Home Administrator confirmed that no investigation was conducted, citing the resident's lack of complaint and questioning the emotional tone of the CNA's statement. The surveyor found no documentation or evidence of an investigation into the alleged abuse, which constitutes a failure to respond appropriately to an allegation of abuse as required by facility policy.
Failure to Prevent Accidents and Inadequate Fall Investigations
Penalty
Summary
The facility failed to ensure that six residents received adequate supervision and assistance devices to prevent accidents, as required by policy. Multiple incidents were not thoroughly investigated, and root causes were not determined, which led to missed opportunities for implementing effective interventions. For example, one resident with dementia and a high fall risk experienced multiple falls, including one resulting in a hip fracture. After being observed ambulating alone, no additional interventions were implemented, and the resident was not assessed by an RN prior to being placed in a wheelchair post-fall, despite RN availability. The facility's investigations into these falls did not include comprehensive root cause analyses. Another resident fell from a wheelchair, but the investigation did not address how the resident was seated, whether the resident was interviewed, or why the fall care plan was not developed until months later. Additionally, the resident was not transferred according to the established plan of care at the time of the fall. In another case, a resident-to-resident altercation was not investigated, and no revisions were made to the care plan following the incident. The facility also failed to investigate how a resident rolled out of bed multiple times despite interventions such as body pillows, and did not consistently determine the root cause of these falls. Further deficiencies included a resident who experienced multiple unwitnessed falls, with investigations failing to determine if previous interventions were in place or to identify root causes. The resident's wander alert bracelet was also improperly placed. Another resident's fall interventions, such as a fall mat and body pillows, were not in place or were incorrectly positioned at the time of a fall, and care plan updates were delayed. In several cases, care planned interventions, such as toileting schedules, were not followed, and falls were not thoroughly investigated to ensure interventions were in place. These failures resulted in actual harm for one resident and the potential for more than minimal harm for others.
Deficient Food Storage, Preparation, and Staff Hygiene Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food storage, preparation, and service practices. Observations revealed that temperature logs were not maintained for unit refrigerators and freezers, and there were no thermometers present in these units. Several food items, including ice cream, yogurt, ribeye, fries, onion rings, tamale pie filling, chicken, pork loins, pancakes, potatoes, and beef top round, were found undated in both the kitchen and unit freezers. Additionally, water was observed dripping from the freezer into the refrigerator, and there was no documentation to show that temperatures were being monitored as required by the facility's own policies. Further inspection showed that hand scoops were left inside bins of sugar, flour, and rice flour, with the scoops in direct contact with the food. The bins themselves were dirty on the outside, with dried and sticky food residue present. The facility's policies require scoops to be kept covered and outside the bins, and for bins to be regularly cleaned and sanitized, but these procedures were not being followed. Staff interviews confirmed that there was no regular cleaning schedule for these bins and that responsibility for dating and storing food items was inconsistently assigned between kitchen and nursing staff. Additionally, a kitchen staff member was observed preparing food without a beard guard, despite having visible facial hair. The facility's policy mandates the use of beard covers when around exposed foods, but the staff member and executive chef did not consider a two-day beard growth to be an issue. The staff member was later observed to be clean-shaven, but no explanation was provided for the initial non-compliance. These failures in food safety practices had the potential to affect all residents in the facility.
Infection Control Program Deficiencies and Lapses in Precaution Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by multiple deficiencies observed during survey. The infection preventionist was not calculating baseline rates of infections for prevalent infections, instead only tracking an overall infection rate. This omission was confirmed during interviews and review of infection control documentation, where it was noted that individual rates for specific infections were not being tracked until after the surveyor's inquiry. Additionally, the facility did not consistently flush the eye wash station weekly as required, with documentation missing for two weeks in May and no designated backup staff to perform the task in the primary staff member's absence. Several residents with stage 2 pressure injuries or other qualifying conditions were not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. For example, one resident with a stage 2 coccyx pressure injury was not on EBP, and staff were observed providing personal care and wound treatment without wearing gowns or following proper PPE protocols. Similar lapses were observed with other residents who had stage 2 pressure injuries, where EBP signage and PPE were not present, and staff were not aware of or did not implement EBP. Interviews with staff revealed a lack of clarity regarding which wounds required EBP and who was responsible for initiating these precautions. Hand hygiene deficiencies were also identified, particularly during medication administration. A nurse was observed failing to perform hand hygiene before donning gloves and between tasks, including when handling medications and administering eye drops. Additionally, a resident with an indwelling catheter was repeatedly observed with the catheter bag and tubing resting directly on the floor without a privacy cover or barrier, contrary to facility policy and infection control standards. These failures in infection prevention practices had the potential to affect all residents in the facility.
Failure to Provide Written Bed-Hold Notification and Rate at Time of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer/discharge, bed-hold policies, and the specific daily rate for bed-hold to four residents and/or their representatives at the time of transfer to the hospital. In each case, the facility's process involved obtaining verbal consent for bed-hold from the resident or their representative, but did not include providing the required written documentation as outlined in the facility's own policy. The documentation reviewed by the surveyor consistently lacked the specific daily rate for holding the bed, and written notices were not given to the residents or their representatives at the time of transfer. For example, one resident with multiple diagnoses including dementia, atrial fibrillation, and diabetes was transferred to the hospital on two separate occasions. In both instances, the transfer, bed-hold notice, and readmission rights forms were completed after the transfer, with only verbal consent documented and no written notice or specific daily rate provided. Another resident with dementia and heart failure was transferred following a fall, and the resident's power of attorney was notified verbally, but again, no written notice or bed-hold rate was provided. Interviews with staff confirmed that the process relied on verbal communication and that written notices were not routinely sent to residents or their representatives. Additional cases included a resident with myelodysplastic syndrome and another with chronic obstructive pulmonary disease, both of whom were transferred to the hospital. In these cases, the bed-hold forms in the medical records did not specify the daily rate, and staff interviews revealed that the rate was only provided at admission, not at the time of transfer. The surveyor confirmed with the nursing home administrator that the daily rate was not included on the transfer documents, and that written notification was not provided as required.
Failure to Prevent Unauthorized Self-Administration of Medications
Penalty
Summary
A resident with a diagnosis of dementia and a moderate cognitive impairment, as indicated by a BIMS score of 11, was observed with a cup containing seven medication pills on the over bed table in their room. The resident's self-administration of medication assessment documented that they were not approved to self-administer medications. Despite this, an LPN left the medications with the resident at the resident's request, and documented the medications as administered on the MAR. There was no licensed nurse or medication tech present in the room at the time the medications were left with the resident. Facility policy requires that residents may only self-administer medications if the interdisciplinary team determines it is clinically appropriate, and this determination must be documented in the resident's record. The resident's assessment indicated they were not approved for self-administration, yet staff allowed the resident to have unsupervised access to their medications. The incident was confirmed through observation, staff interviews, and record review, with no explanation provided by the facility for the failure to follow policy and assessment findings.
Failure to Timely Revise Care Plans After Resident Status Changes
Penalty
Summary
The facility failed to ensure that care plans were promptly and accurately revised following significant changes in the condition or care needs of two residents. For one resident with dementia, atrial fibrillation, and a recent right humerus fracture, the mobility care plan was not updated after therapy changed the resident's transfer status from a two-person assist to a one-person assist with a wheeled walker. Despite therapy's recommendation being documented, the care plan continued to reflect the original intervention, and this discrepancy was identified after the resident experienced a fall during a transfer with staff assistance. Another resident with Alzheimer's, dementia, and severe malnutrition developed a stage 2 pressure injury to the right heel. Although nursing staff documented the injury and new interventions were ordered, the resident's care plan was not revised to include these interventions until several weeks later. The care plan was only updated after a significant delay, despite the facility's policy requiring care plan revisions upon status changes. The delay in updating the care plan meant that the interventions for the pressure injury were not reflected in the resident's official care plan documentation in a timely manner. Interviews with facility staff confirmed that care plan revisions were not completed immediately following changes in resident status, and that updates to task sheets did not automatically update the care plan. The surveyor was unable to locate documentation of the interventions in the resident's CNA Kardex or determine when certain interventions were initiated, further highlighting the lack of timely care plan updates.
Failure to Prevent and Manage Pressure Injuries and Monitor Skin Integrity
Penalty
Summary
Surveyors identified that the facility failed to provide necessary treatment and services to prevent and treat pressure injuries for three residents. One resident was admitted with moisture-associated skin damage (MASD) and later developed open areas on the buttocks, which were not reassessed as stage 2 pressure injuries in a timely manner. Weekly skin assessments were not completed as required, and the care plan was not revised after the development of new open areas. The resident was also observed sitting in a recliner without a pressure-relieving cushion, despite reporting discomfort and using a bed pillow for relief. Another resident developed a pressure injury on the coccyx, but comprehensive assessments were not completed when the injury was first identified. There were multiple nursing notes documenting an open area on the coccyx, but no detailed assessment or treatment was initiated until over a month later. The care plan was not updated promptly, and the resident was repeatedly observed sitting in a personal recliner without a pressure-relieving cushion, contrary to care plan interventions for pressure relief. A third resident wore a wanderguard directly on the skin without a sock underneath, and there was no documentation of daily skin checks under the device, despite the risk for skin breakdown. The care plan and physician orders did not initially include interventions to monitor skin integrity under the wanderguard, and nursing staff confirmed that skin checks were not being performed. The deficiency was only addressed after surveyor intervention, with no evidence of prior monitoring or documentation.
Failure to Perform and Document Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that residents with diabetes mellitus received routine diabetic foot checks in accordance with professional standards of practice. Three residents with diabetes, each with additional risk factors such as diabetic neuropathy, chronic kidney disease, and polyneuropathy, did not have documentation of daily diabetic foot checks in their medical records. The care plans for these residents either lacked specific interventions for daily foot checks or did not address foot checks at all, despite the presence of diabetes and related complications. Interviews with nursing staff, including a Registered Nurse/Unit Manager, revealed that only weekly skin checks were performed during shower checks, and daily diabetic foot checks were not conducted or documented. The staff indicated that Certified Nursing Assistants were expected to document these checks, but no evidence of such documentation was found for the residents in question. When asked, the staff confirmed that daily foot checks for residents with diabetes were not part of their routine practice. The facility's own Skin Integrity-Foot Care policy requires foot care and treatment to be provided in accordance with professional standards, including systematic prevention and management of foot ulcers and regular monitoring. However, the policy was not followed for the residents identified, as there was no documentation or evidence of daily diabetic foot checks being completed. The deficiency was confirmed through record review and staff interviews, with no additional information provided by the facility to explain the lack of compliance.
Failure to Monitor for Anticoagulant Complications
Penalty
Summary
The facility failed to ensure that the drug regimens of three residents prescribed anticoagulant medications were free from unnecessary drugs by not monitoring for signs and symptoms of anticoagulant complications as required. For each of these residents, the care plans and physician orders included the use of anticoagulants such as Eliquis (Apixaban) and Rivaroxaban for conditions like pulmonary embolism, atrial fibrillation, and blood clots. However, there was no evidence in the medical records, medication administration records, progress notes, or assessments that staff were monitoring for adverse effects such as bleeding, bruising, changes in mental status, or abnormal vital signs. Interviews with nursing staff and review of facility policy revealed that while staff were aware of the need to monitor for complications associated with anticoagulant therapy, this monitoring was not documented or ordered in the residents' records. The facility's policy on high-risk medications specifically requires staff to monitor and document for adverse consequences of anticoagulant use, including bleeding and thromboembolism, and to alert staff through the care plan. Despite this, the surveyor was unable to locate any documentation of such monitoring for the three residents in question. Additionally, one resident's care plan did not include any interventions related to anticoagulant monitoring, and there was no physician order to monitor for complications. Nursing staff confirmed that monitoring was based on nursing judgment and not consistently documented. The facility did not provide any explanation for the lack of daily monitoring for signs and symptoms of anticoagulant complications in these residents.
Failure to Ensure Hospice Collaboration and Documentation
Penalty
Summary
The facility failed to ensure proper collaboration and communication with hospice providers for three residents receiving hospice services. For each of these residents, the current hospice plan of care, visit notes, and schedules of hospice providers were not consistently available to facility staff. In addition, the facility did not designate a staff member to coordinate the plan of care with the hospice provider, and in some cases, did not develop a facility hospice care plan at all. These deficiencies were identified through interviews and record reviews, which revealed gaps in documentation, lack of clear processes for communication, and inconsistent maintenance of hospice records. One resident with multiple diagnoses, including dementia, atrial fibrillation, diabetes, and colon cancer, was receiving hospice care, but the facility's records lacked up-to-date hospice communication notes and schedules after a certain date. The hospice binder contained some documentation, but there were missing notes for recent hospice visits, and staff interviews indicated uncertainty about who was responsible for ensuring hospice notes were provided and uploaded into the medical record. There was also no clear designation of a hospice liaison among facility staff, and the process for communication with hospice was inconsistent. Another resident with Alzheimer's disease and other conditions was also on hospice, but the hospice binder contained no communication notes after a certain date, and the interdisciplinary team form was not filled out. Staff interviews revealed that hospice visit forms were sometimes uploaded into the medical record, but not consistently, and there was no designated hospice liaison. The process for documenting and communicating hospice care was unclear, and schedules for hospice visits were not consistently provided. These findings were consistent across multiple residents, indicating a systemic issue with hospice collaboration and documentation within the facility.
Failure to Immediately Report and Respond to Allegation of Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to implement its written policies and procedures to prohibit and prevent verbal abuse, resulting in a resident not being protected from such abuse by a registered nurse. The incident involved a resident with chronic kidney disease, anemia, chronic congestive heart failure, and dementia, who was assessed as having severely impaired decision-making abilities. During the early morning hours, a certified nursing assistant overheard a registered nurse making inappropriate and verbally abusive remarks to the resident during toileting care. The certified nursing assistant immediately reported the incident to an LPN, who did not escalate the allegation to the nursing home administrator, director of nursing, or director of social services until the end of the shift. As a result of the delayed reporting, the registered nurse continued to work the remainder of the shift, providing care and passing medications to other residents, which allowed for the possibility of further incidents of verbal abuse. The facility's policy required immediate reporting of abuse allegations to the appropriate administrative staff, but this was not followed. The surveyor confirmed through interviews and record reviews that the LPN was aware of the allegation at approximately 4:30 AM but did not notify the required personnel until after the shift ended, and the registered nurse was not removed from resident care areas until then. Further review revealed that the facility did not collect or investigate statements from all staff present during the shift, which could have provided additional information or identified a pattern of abusive behavior by the registered nurse. The director of social services confirmed that some staff statements were not submitted to the state survey agency, considering them hearsay. The incident left both the resident and the reporting certified nursing assistant visibly distressed, and the facility did not immediately place the resident on the follow-up report board for monitoring after the allegation was made.
Failure to Immediately Report Alleged Verbal Abuse
Penalty
Summary
An allegation of verbal abuse was made against a registered nurse (RN) who was reported to have made inappropriate comments to a resident during toileting assistance in the early morning hours. The certified nursing assistant (CNA) who overheard the comments immediately reported the incident to the licensed practical nurse (LPN) on duty. However, the LPN did not immediately escalate the allegation to the Nursing Home Administrator (NHA), Director of Nursing (DON), or Director of Social Services (DSS) as required by facility policy. Instead, the LPN waited until the end of the shift to inform the DON, allowing the RN accused of verbal abuse to continue working and have contact with other residents until the shift ended. The resident involved had significant medical conditions, including chronic kidney disease, anemia, congestive heart failure, and dementia, with a severely impaired ability to make daily decisions as indicated by a low BIMS score. The resident required substantial assistance with activities of daily living and was described as typically happy and thankful, making the reported behavior and distress during the incident notable. The incident was documented in the resident's electronic health record, including the resident's emotional distress and statements expressing a wish to die, which were addressed by the RN in the documentation. Interviews with staff confirmed that the LPN was made aware of the alleged abuse at approximately 4:30 AM but did not notify facility leadership until after the shift ended. The RN remained on duty and continued to provide care, including passing medications, until leaving the facility at the end of the shift. The delay in reporting the allegation was contrary to the facility's written policies, which require immediate reporting of abuse allegations to the appropriate authorities to ensure resident protection and compliance with regulatory requirements.
Failure to Investigate Alleged Verbal Abuse and Protect Resident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a registered nurse and a resident with severe cognitive impairment. The incident occurred when a certified nursing assistant overheard the nurse making inappropriate comments to the resident during early morning care. The certified nursing assistant immediately reported the incident to an LPN, who did not escalate the report to facility leadership until the end of the shift, allowing the alleged perpetrator to continue working and have contact with other residents. The nurse was not immediately removed from resident care areas, contrary to facility policy. The investigation into the incident was incomplete. Statements from three staff members who were present during the shift were not collected or submitted to the state survey agency, and the facility did not follow up on these missing statements. Additionally, the facility did not update the resident's care plan to address any psychosocial issues that may have arisen from the incident. The director of social services did not notify the resident's psychologist about the resident's expressions of distress, including statements about not wanting to live, which were documented in the medical record but not communicated to the appropriate mental health professional. The resident involved had a history of chronic kidney disease, anemia, congestive heart failure, and dementia, with a severely impaired mental status and dependence on staff for most activities of daily living. At the time of the incident, the resident had recently experienced a decrease in antidepressant medication and was noted to be more confused and anxious. Despite these changes and the resident's expressions of emotional distress following the alleged verbal abuse, there was no documented follow-up or emotional support provided, and the facility did not ensure that all required investigative and protective actions were taken as outlined in their own policies.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings accurately reflected the actual staffing present in the building. Over a 30-day review period, surveyors identified discrepancies on 14 days between the posted staffing information and the actual staff schedules. These discrepancies included incorrect numbers and types of licensed and unlicensed nursing staff, as well as inaccurate reporting of actual hours worked per shift. The facility's policy required that nurse staffing sheets be updated daily and reflect real-time changes such as callouts and absences, but this was not consistently done. Interviews revealed that the night shift was responsible for posting the new staffing information each day, while nursing staff were expected to update postings as changes occurred. However, the staff member responsible for filing postings and schedules admitted to no longer reviewing the postings for accuracy against the schedules. This lapse resulted in multiple instances where the posted information did not match the actual staffing, potentially affecting all 41 residents in the facility during the review period.
Failure to Prevent Falls and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for two residents reviewed for falls. One resident, admitted with pulmonary heart disease and chronic diastolic heart failure and receiving hospice services, experienced five unwitnessed falls within a little over a month. Three of these falls occurred during self-toileting attempts, and interventions such as a toileting plan, fall mat, and bed in the lowest position were inconsistently documented between the care plan and the Kardex. The resident's care plan did not reflect all interventions implemented, and there was a lack of thorough root cause analysis after each fall. The final fall resulted in a displaced left femoral neck fracture, and the fall mat was not in place at the time. Additionally, the resident was not assessed by an RN before being moved after the fall. Another resident, admitted with parkinsonism and a history of falls, fell forward from a wheelchair and sustained a head injury requiring sutures. At the time of the incident, the resident was being transported by staff without wheelchair foot pedals in place, despite requiring staff assistance for mobility and not propelling the wheelchair independently. The care plan was updated to include the use of foot pedals for out-of-facility appointments only after the fall occurred. Staff interviews confirmed that the pedals were not applied at the time of the fall, and the incident happened quickly as the resident was being wheeled out of the room. In both cases, the facility's failure to implement and document individualized interventions, ensure consistent communication between care plans and task lists, and provide adequate supervision directly contributed to the residents' falls and injuries. The lack of thorough investigation and timely updates to care plans following each incident further contributed to the deficiencies identified by surveyors.
Failure to Classify Fall and Incorrect Transfer Method
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) classified an incident involving a resident found on the floor as a fall, which led to the omission of necessary post-fall protocols. The resident, who had a history of dementia, orthostatic hypotension, and repeated falls, was found on the floor by a Certified Nursing Assistant (CNA) but the LPN did not document it as a fall. Consequently, the LPN did not initiate a fall investigation, complete a post-fall evaluation, or communicate the fall to the oncoming shift, as required by the facility's policies. Additionally, the facility did not ensure that Certified Nursing Assistants (CNAs) used a Hoyer lift for transferring a resident as per the resident's care plan. The resident, who had a history of hemiplegia, morbid obesity, and vascular dementia, was transferred using an EZ stand lift instead of the required Hoyer lift. This incorrect transfer method was used despite the resident's care plan and therapy recommendations specifying the need for a Hoyer lift, leading to a near-fall incident. Interviews with staff revealed a lack of adherence to the facility's policies and procedures regarding fall management and resident transfers. The LPN involved did not recognize the incident as a fall, and the CNAs involved in the transfer incident were not fully aware of the resident's transfer requirements. The Director of Nursing (DON) and the Administrator expressed expectations that staff should follow care plans and policies, but these were not met in the incidents described.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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