Watertown Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Watertown, Wisconsin.
- Location
- 121 Hospital Dr, Watertown, Wisconsin 53098
- CMS Provider Number
- 525333
- Inspections on file
- 39
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Watertown Health Care Center during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate and resolve grievances related to missing personal property and laundry items. Several residents reported that clothing, socks, and a nightgown were missing, and that staff were aware but did not provide updates or document these concerns in the grievance log, despite ongoing discussion of missing items in Resident Council meetings. Laundry staff described an inconsistent admission inventory and labeling process, reliance on an informal bulletin board to track missing items, and frequent loss of unlabeled clothing. In a separate case, a cognitively intact resident’s borrowed wheelchair went missing shortly after admission; although a grievance was filed and a replacement wheelchair provided, the investigation did not include broader staff or resident interviews, and no admission inventory of the resident’s belongings was found in the medical record.
The facility failed to follow its abuse/neglect/exploitation policy requiring timely caregiver background checks for multiple CNAs, an activity aide, and a maintenance staff member. For several staff, BID forms and DOJ/GF reports were either missing, completed after the hire date, or not updated within the required four-year interval, yet these individuals were allowed to work with residents or in resident care areas. Leadership acknowledged that background checks are required prior to staff working with residents and that responsibility for this process had been assigned to a former business office manager.
The facility failed to develop and implement individualized comprehensive care plans for three residents with clearly identified needs. One resident who reported theft of money did not receive a care plan for safe keeping of valuables despite the facility’s investigation indicating one would be implemented. Another resident with end stage renal disease, documented on the MDS as receiving dialysis, had no dialysis care plan in the medical record. A third resident with Alzheimer’s disease and moderate cognitive impairment, known by CNAs to exhibit dementia-related behaviors such as refusing to get out of bed, had no Alzheimer’s/dementia care plan or related interventions documented. Facility leadership, including the DON and CNO, confirmed these omissions.
Surveyors found that the facility failed to administer and document medications accurately and on time for multiple residents. One resident with multiple severe pressure ulcers had an acetic acid order lacking specific application instructions, with numerous missed doses coded as “other” and no explanatory notes; staff, including an LPN and the DON, did not know where or why it was to be applied, and a staff member admitted documenting doses as given that they had not administered. Another resident’s methenamine for recurrent UTIs was not restarted when specified in hospital discharge instructions after a sepsis hospitalization. Several residents received routine morning medications, including antipsychotics, antidepressants, antihypertensives, antidiabetics, and anticoagulants, significantly later than their ordered times, and one resident’s cardiac and rheumatologic medications were repeatedly not given because they were unavailable. A resident with epilepsy reported small seizures when seizure medications were given late, and MAR review showed multiple late or irregularly timed doses of lacosamide and levetiracetam, with some entries coded as “other” and lacking corresponding nursing notes.
Surveyors found that staff did not consistently follow the facility’s infection control and hand hygiene policies. A CNA providing peri and catheter care to a resident on enhanced barrier precautions failed to change gloves and perform hand hygiene when moving from soiled to clean tasks and touched the resident and supplies with contaminated gloves. An assistant administrator entered the room of a resident on contact precautions for CRAB without performing hand hygiene or donning required PPE, then went to another room without hand hygiene. An RN prepared and administered medications to several residents without performing hand hygiene as required by policy. During multiple meal services, residents were not offered hand hygiene, meal trays lacked wipes, and dining tables had no wipes or hand sanitizer, despite staff acknowledging that residents should be offered hand hygiene before meals.
Two residents with serious infections did not receive multiple ordered IV antibiotic doses due to issues such as delayed PICC placement and pharmacy non-availability, and staff did not document timely physician notification of these missed doses. One resident with osteomyelitis and multiple pressure ulcers missed doses of ceftriaxone and vancomycin when the PICC line was not yet placed and medications were not available, with MAR codes indicating held or other but no record of provider contact. Another resident admitted with sepsis, cellulitis, and a history of MRSA missed several scheduled doses of IV cefazolin attributed to pharmacy issues, later sought ED care after expressing concern about going without antibiotics, and the DON acknowledged that the provider was not contacted until after multiple doses were missed, with no clear documentation of the notification in the record.
A resident with paraplegia and a baclofen pump experienced multiple missed and delayed pre‑op and surgical appointments due to unreliable transportation coordination. The facility failed to schedule a ride and complete required blood work for one pre‑op visit, did not hold the resident’s Eliquis in time for another attempt, and a transportation company arrived with an inappropriate vehicle instead of a wheelchair van on a subsequent occasion. Progress notes and an APNP note documented that the pre‑procedure physical and baclofen pump replacement surgery were delayed multiple times because of transportation issues. Transportation staff, the RN, DON, and NHA acknowledged missed appointments and transportation problems, and the surveyor was not provided with staff education for the updated transportation process when requested.
The facility failed to submit the final results of an abuse investigation to the State Agency within the required five working days. After a family visit, a resident with intact cognition exhibited a significant escalation in behavior, and a family member reported that another family member may have previously provided the resident with illicit substances. The facility submitted the initial abuse allegation as a facility-reported incident, but the final misconduct investigation report was not completed and submitted by the CNO until several days past the required deadline, despite leadership acknowledging awareness of the five-day reporting requirement.
A resident who required staff assistance for toileting and hygiene reported that the facility repeatedly ran out of the correct size briefs and wipes, leading staff to improvise with multiple briefs and sometimes skip cleansing during changes. Staff interviews, including an LPN and CNA, confirmed ongoing shortages of briefs, wipes, and wash cloths, with supplies often depleted by week's end and residents voicing complaints. The central supply clerk and administrator acknowledged supply issues, and no supply policy was provided during the survey.
A resident with multiple medical and mental health conditions, who was dependent on staff for personal care, reported discomfort when a male visitor remained in the room during care activities. Staff were aware of the resident's concerns, but the facility lacked a policy on visitor presence during care, resulting in inadequate privacy for the resident.
A resident with a tracheostomy did not receive care consistent with professional standards when an LPN failed to maintain sterile technique and proper hand hygiene during a tracheostomy care procedure. Supplies were placed on an unclean bedside table, sterile items were contaminated, and hand hygiene was not performed after glove removal. The LPN also did not check the resident's neck for skin breakdown as required.
Two CNAs failed to follow infection prevention protocols while providing peri-care to a resident who required assistance with hygiene. The CNAs used soiled gloves to touch the resident and various items in the room without changing gloves or performing hand hygiene between tasks, despite facility policy requiring these actions. Both CNAs later confirmed they did not follow proper procedures.
A resident's funds were not conveyed within the required 30 days post-discharge, as the facility failed to provide a final accounting or refund of the remaining balance. The resident's HCPOA did not receive the funds due to an incorrect mailing address, despite multiple contacts with the facility.
The facility exhibited significant deficiencies in its infection control program during a COVID-19 outbreak. Staff failed to use appropriate PPE, worked with symptoms without testing, and did not isolate COVID-positive residents effectively. Additionally, there were lapses in hand hygiene and documentation of water management control measures, contributing to the potential for widespread harm.
A resident with a midline catheter for IV antibiotic treatment experienced complications due to improper management by facility staff. The catheter could not be flushed, and despite being reported, there was a delay in assessment. An RN attempted removal without a physician's order, resulting in the catheter breaking and a piece being retained in the resident's arm. The facility failed to follow policies, document monitoring, and ensure staff competency, leading to an Immediate Jeopardy situation.
The facility failed to assess residents' cognitive ability to understand arbitration agreements and did not ensure staff could adequately explain these agreements. Several residents and their representatives were unaware that signing the agreement meant forfeiting their right to use the judicial system for disputes. The Admissions Coordinator lacked understanding of the agreement's implications, leading to residents' misunderstanding and dissatisfaction.
The facility failed to supervise the charging of electric wheelchairs according to policy, leading to them being charged in residents' rooms. Staff interviews revealed a lack of awareness about the correct procedure, despite the policy requiring charging in a designated area away from residents' sleeping quarters.
The facility did not ensure food was served at appropriate temperatures, as evidenced by a surveyor's test tray and resident interviews. Hot foods were served cold and cold foods were warm, contrary to the facility's policy. Two cognitively intact residents reported receiving cold meals, and the Dietary Manager acknowledged the issue, noting that bottom plates to maintain temperature were not used due to difficulty for residents eating in bed.
A resident was observed with medications at their bedside without a completed self-administration assessment, contrary to facility policy. The resident, who was cognitively intact, had multiple medications, including eye drops and nasal sprays, on their bedside table without secure storage. The facility's policy requires an interdisciplinary team assessment and secure storage for self-administered medications, which were not adhered to in this case.
The facility failed to accurately code MDS assessments for two residents. One resident's MDS incorrectly indicated they were deceased upon discharge, while another resident's MDS did not reflect a gradual dose reduction of Risperdal. These discrepancies were identified during a review and interview with the DON.
A resident with dementia and other conditions was prescribed Risperdal, an antipsychotic medication, but did not receive timely AIMS testing as required by facility policy. The last AIMS test was conducted over a year ago, missing at least three quarterly assessments. The DON acknowledged the oversight in adhering to the policy for monitoring psychotropic medication effects.
A medication error rate of 6.45% was identified in the facility, exceeding the acceptable 5% threshold. An LPN failed to prime insulin pens before administering insulin to a resident with Type 2 Diabetes Mellitus, contrary to manufacturer's instructions. The facility's policy lacked guidance on priming insulin pens, contributing to the error.
A resident in an LTC facility did not receive prescribed doses of insulin and Metoprolol Tartrate due to transcription errors in the electronic medical record. The MAR showed blank spaces for these medications, and the resident confirmed the omissions. The DON acknowledged the error and provided verbal education to the responsible LPN but did not educate all nursing staff.
The facility failed to implement its antibiotic stewardship program effectively, leading to inappropriate antibiotic use for two residents. One resident was treated for cellulitis without meeting the McGeer Criteria, lacking sufficient symptoms. Another resident was treated for pneumonia without a confirming chest x-ray or meeting necessary criteria. Interviews confirmed the failure to adhere to established protocols.
A resident, who is cognitively intact and requires assistance due to physical limitations, reported feeling infantilized as staff often refused to assist her out of bed after using the bedpan. Despite her requests and the facility's expectations, staff frequently left her in bed, particularly during shift changes, failing to respect her dignity and rights.
Two residents in a LTC facility experienced unresolved grievances due to staff inaction. One resident, with a history of stroke and other conditions, was not assisted in getting up after using a bedpan, despite expressing concerns. Another resident, dependent on staff for toileting, was left on a commode for an extended period and did not receive a resolution to her grievance. The facility's grievance policy was not followed, leading to deficiencies in handling these concerns.
Two residents in an LTC facility did not receive care according to professional standards. One resident's pacemaker monitoring system was unplugged, preventing data transmission to the cardiac clinic. Another resident, with congestive heart failure, was not weighed daily as ordered, with missing entries for nine days. Staff interviews revealed lapses in care plans and communication.
The facility failed to properly label and store medications, affecting two medication rooms, a medication cart, and a resident who self-administers medication. Observations included an unlabeled insulin pen, a Tuberculin vial without an open date, and expired medications. A resident was found with medication in an unlocked drawer, contrary to facility policy. Staff interviews confirmed these deficiencies.
A resident at risk for pressure injuries developed an unstageable pressure injury due to the facility's failure to implement aggressive preventive measures and update the care plan. Despite recommendations for a mattress upgrade, the resident remained on the same foam mattress, and grievances were filed regarding long wait times for assistance, contributing to inadequate care.
A resident with chronic respiratory issues experienced severe respiratory distress, but the LPN failed to recognize it as an emergency, delaying appropriate treatment. Despite critically low oxygen levels, the LPN did not perform a comprehensive assessment or consult with an RN, leading to a delay in calling emergency services. The resident was eventually transported to the hospital but was pronounced dead shortly after arrival.
A resident at high risk for falls experienced multiple incidents due to the facility's failure to promptly update care plans and communicate interventions to staff. Despite a history of falls and medical conditions, necessary interventions were delayed or omitted, leading to repeated falls and injuries, including a laceration requiring stitches.
Two residents experienced a decline in bowel and bladder continence due to the facility's failure to implement appropriate care plans and interventions. One resident, previously continent, became frequently incontinent without a toileting program or updated care plan. The other resident, also experiencing a decline, was left in soiled conditions for extended periods. Staff interviews revealed a lack of awareness and communication regarding the residents' continence status, and the facility's policies on incontinence and care planning were not followed.
The facility failed to provide sufficient nursing staff, affecting all 72 residents. Multiple residents reported long wait times for call lights and unmet basic needs, with some left in soiled conditions for extended periods. Staff confirmed they were unable to complete all tasks due to insufficient staffing, leading to significant delays in care. Despite recognizing the issue, the facility's staffing was based on census rather than residents' needs, resulting in persistent care delays and resident frustration.
A resident with multiple health conditions was forced to wear a nightgown due to a lack of clean clothes, leading to embarrassment and isolation. Despite being cognitively intact, the resident felt uncomfortable participating in communal activities and dining, as confirmed by staff observations. The facility's failure to provide clean clothes compromised the resident's dignity and self-determination.
The Bedrock Corporation failed to maintain current payments with service providers, leading to potential disruptions in essential services for 72 residents. The facility's pharmacy provider terminated services due to unpaid invoices, and significant amounts are owed to other vendors, including Sysco and Point Click Care. Delinquent property taxes and utilities further exacerbate the situation, posing risks to resident care and facility operations.
A resident with a history of intentional overdose was observed with medications at her bedside without a self-administration assessment. Despite being cognitively intact, she was dependent on staff for daily activities and had no physician's order to self-administer medications. Interviews with staff revealed that medications were often left at her bedside, contrary to the facility's policy and safety protocols.
Two residents in a facility were not allowed to choose their attending physician, contrary to their rights. One resident was required to see the in-house physician and nurse practitioner, and her medication was discontinued without her consent. Another resident was unaware of her right to choose her physician and missed a nephrology appointment due to a scheduling error and lack of staff assistance. Both residents were cognitively intact, and the Director of Nursing was unaware of these issues.
A resident with a history of intentional overdose was left unsupervised with medications at her bedside, despite facility policies requiring supervision and risk assessment. The resident's care plan lacked specific safety interventions, and staff interviews confirmed the practice of leaving medications unsupervised, highlighting a failure to ensure the resident's safety.
During a tornado warning, the facility failed to follow its safety procedures, leaving residents in potentially hazardous situations. Despite the policy requiring relocation to safe areas and provision of protective items, staff did not move residents or provide necessary protection. Interviews revealed inconsistent actions and a lack of adherence to emergency procedures.
A resident with moderate cognitive impairment and multiple health conditions experienced verbal and mental abuse by a CNA following a verbal altercation. The CNA wrote a threatening letter to the resident, which was discovered and reported by staff. The facility's investigation revealed the CNA's confession, highlighting a failure to protect the resident from abuse, resulting in a finding of Immediate Jeopardy.
A facility failed to report an alleged abuse incident involving a threatening note from a CNA to a resident with moderate cognitive impairment and multiple health issues. Despite starting an investigation and involving the police, the incident was not reported to the State Agency as required. The Nursing Home Administrator incorrectly used an algorithm for resident-to-resident abuse to decide not to report the incident.
A resident with a history of bowel obstructions and UTIs was not adequately monitored by the facility. Despite presenting symptoms of nausea, vomiting, and abdominal pain, the facility failed to conduct thorough assessments or continuous monitoring, such as obtaining vital signs and observing urine appearance. Interviews with staff revealed that necessary monitoring and documentation were not performed, contributing to the deficiency in care.
The facility failed to report an incident of non-consensual sexual touching to the state agency within the required timeframe. A resident reported that another resident entered her room, touched her buttock, and pulled his pants down. Despite the incident being reported to facility staff on the same day, the facility did not report it to the state agency until two days later, after receiving additional information from the psych NP.
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with known self-injurious behavior and a history of substance abuse. Despite measures like a no-trespassing order for the resident's brother and required supervised visitations, the facility did not adequately inform all staff, allowing the brother to visit and provide drugs to the resident, resulting in further substance abuse.
Failure to Thoroughly Investigate and Resolve Grievances About Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve resident grievances related to missing personal items and laundry, and to consistently follow its grievance and personal property policies. Multiple residents reported that laundry items such as clothing and socks frequently went missing. One resident, who was also the Resident Council president, stated that missing laundry was a recurring issue discussed at Resident Council meetings and wanted staff to resume bringing unclaimed personal items from laundry for residents to sort through. Another resident reported missing pajama pants and a sweater, stating the Nursing Home Administrator was aware and had said the items would be replaced, but this had not occurred. A further resident reported a missing nightgown with cardinals, and both that resident and the roommate indicated staff were aware but had not located the item or provided an update. Review of Resident Council minutes showed that missing clothing and lost-and-found items had been discussed in prior meetings, and staff had acknowledged working on an improved process to decrease missing items. Despite this, the grievance log contained no entries for the residents’ missing items. In the laundry area, the surveyor observed a bin of unlabeled clothing and a bulletin board listing residents’ names and missing items, which laundry staff used informally to track lost belongings. Laundry staff reported that residents’ belongings were supposed to be inventoried on admission and sent to laundry for labeling, but this process was inconsistent, and items were often laundered before being labeled. Laundry staff also stated that they were not always informed when items were missing, and that missing items occurred almost daily. Another component of the deficiency involved a resident whose borrowed brown wheelchair went missing shortly after admission. The resident, who had intact cognition and used a wheelchair, reported telling multiple staff about the missing wheelchair and expressed a desire to have the friend’s wheelchair returned. A grievance documented that the care team reported the missing wheelchair, that staff searched the facility and interviewed the receptionist, and that a new wheelchair was provided, with the grievance noting the resident was reportedly satisfied and had no further complaints. However, the grievance did not include interviews with other staff or residents to determine if anyone else had seen the wheelchair or knew its whereabouts. Additionally, the resident’s medical record lacked an admission inventory of belongings, and the Assistant DON confirmed that while belongings should be inventoried and documented, no such inventory was found for this resident.
Failure to Complete Required Caregiver Background Checks Before Staff Worked With Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written Abuse/Neglect/Exploitation policy requiring screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credential checks. Surveyor review of 10 staff files on 3/11/26 showed that 6 staff members did not have timely or properly completed caregiver background checks. One CNA hired on 6/24/16 had a Background Information Disclosure (BID) form dated 6/23/16, but the Department of Justice (DOJ) and Government Findings (GF) reports were not completed until 3/11/26, after the surveyor requested them, and not within the required four-year interval. Another CNA hired on 1/29/26 had a BID form dated 1/30/26, completed after the hire date, and there was no evidence that DOJ or GF reports were requested. A third CNA hired on 11/2/04 had a BID form completed on 8/26/16, but the DOJ and GF reports were not completed until 12/29/20, which was not within the last four years. An activity aide hired on 1/24/26 had a BID form dated 1/26/26 and DOJ/GF reports dated 1/27/26, all completed after the hire date, meaning the aide worked with residents before completion of the background check. A maintenance staff member hired on 12/8/25 had DOJ and GF reports dated 12/9/25, after the hire date, and worked in resident care areas before the background check was completed. Another CNA hired on 1/6/26 had DOJ and GF reports dated 1/8/26, also after the hire date. In an interview, the NHA and DON confirmed that the previous business office manager had been responsible for background checks, that this person had left employment a few weeks earlier, and that background checks are required every four years and must be completed before staff work with residents or in resident care areas.
Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement individualized comprehensive care plans addressing specific identified needs for three residents. For one resident with intact cognition and multiple diagnoses including muscle wasting, diabetes, encephalopathy, schizoaffective disorder, and seizures, the facility investigated a facility-reported incident involving an allegation of misappropriation of money. The investigation indicated that a safe keeping of valuables care plan would be implemented, but review of the medical record showed that no such care plan was added. During interviews, facility leadership confirmed that the resident’s care plan did not address safe keeping of valuables and acknowledged that it should have been included. A second resident with end stage renal disease and intact cognition was identified on the MDS as receiving dialysis, yet the medical record contained no dialysis care plan, which was confirmed by the DON. A third resident with Alzheimer’s disease, anxiety, depression, and moderate cognitive impairment, and who had an activated POA for healthcare, was known by staff to have dementia-related behaviors such as sometimes refusing to get out of bed, requiring staff to reapproach later. However, review of this resident’s care plan showed no interventions for Alzheimer’s disease/dementia care. The DON verified that this resident did not have an Alzheimer’s disease/dementia care plan, despite facility policies requiring resident-centered care plans for individuals with dementia and comprehensive care plans describing services to maintain residents’ highest practicable well-being.
Widespread Failures in Timely and Accurate Medication Administration and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and timely medication administration in accordance with physician orders and facility policy for multiple residents. The facility’s Medication Administration policy required medications to be administered as prescribed, within 60 minutes of scheduled times, with clear documentation and clarification of unclear orders. For one resident with multiple severe pressure ulcers and osteomyelitis, an order for 5% acetic acid stated only to apply externally every day and evening shift, without specifying the location, method of application, or treatment parameters. Review of the MAR showed that 11 of 44 scheduled doses were not documented as administered, with 10 doses coded as “other” and one as “refused,” and no corresponding progress notes explaining the “other” codes. Nursing staff, including an LPN and the DON, stated they did not know where the acetic acid should be applied or the indication for its use and acknowledged the order was unclear and should have been clarified. Another staff member reported never applying the acetic acid despite documenting it as given and stated they had been pressured by the wound nurse to sign out medications and treatments they did not administer. A second resident with paraplegia, sepsis, anxiety, and depression had been on methenamine hippurate twice daily for frequent UTIs. After a hospitalization for sepsis with possible UTI, the hospital discharge summary instructed that methenamine be held during a 7‑day course of Bactrim and then resumed three days after completion, specifying a resume date. The facility did not restart methenamine hippurate until 11 days after the date indicated in the discharge instructions. The ADON, who also served as Infection Preventionist, confirmed that the methenamine should have been resumed per the hospital instructions and stated the order had been missed. Additional residents experienced late or unavailable medications and administration not in accordance with orders. One cognitively intact resident reported that morning medications, including olanzapine, glipizide ER, and fluoxetine, were sometimes late; an audit showed these 8:00 AM medications were administered around midday. Another resident admitted with atrial fibrillation, hypertension, and rheumatoid arthritis had multiple essential medications, including amiodarone, hydroxychloroquine, metoprolol, and sulfasalazine, not administered on several days because they were unavailable, as documented on the MAR. Several other residents had scheduled morning medications (including metformin, methenamine, acetaminophen, antihypertensives, anticoagulants, psychotropics, and other chronic medications) ordered for 7:00 or 8:00 AM but observed being administered after 9:00 AM; the RN administering these medications acknowledged they were late and stated that morning medications were given between 7:00 and 11:00 AM. The DON stated medications should be administered within one hour before or after the prescribed time. Another cognitively intact resident with epilepsy, diabetes, asthma, and anxiety reported needing seizure medications on time and stated that seizure medications were given two hours late, leading to small seizures, which the resident described to nursing staff and the DON. The MAR showed multiple doses of lacosamide and levetiracetam scheduled for 8:00 AM and 4:00 PM were administered late, coded as “other,” or documented as given significantly outside the scheduled times, with some doses of levetiracetam administered several hours after the scheduled time. Nurses’ notes for the dates with “other” codes were not available for review, and there were no progress notes documenting seizure activity. A pharmacist later explained that twice‑daily medications are recommended to be given at least eight hours apart and preferably closer to 12 hours, and confirmed that certain doses of levetiracetam were supplied in limited quantities due to insurance refill timing, with the possibility that the resident had home supply, but the MAR still reflected late administrations and code entries.
Failure to Follow Hand Hygiene, PPE, and Meal-Time Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain its infection prevention and control and hand hygiene policies, including during enhanced barrier precautions, contact precautions, medication administration, and meal service. The facility’s policies required hand hygiene before and after resident contact, after glove removal, when moving from soiled to clean body sites, and before medication preparation and administration. Policies also required appropriate use of PPE for residents on contact precautions and mandated that all residents be offered hand hygiene prior to meals. Surveyors found multiple instances where these requirements were not followed. One resident on enhanced barrier precautions due to a catheter and a wound was observed receiving peri care and catheter care from a CNA who did not change gloves or perform hand hygiene when moving from dirty to clean tasks. The CNA washed the resident’s upper body, anterior peri area, and completed catheter care without removing soiled gloves, cleansing hands, and donning clean gloves before touching the resident’s gown. The CNA then removed soiled gloves, retrieved a bottle of hand sanitizer from under the gown and reached into the scrub top without performing hand hygiene, and later washed the resident’s peri rectal area without changing gloves or cleansing hands. The CNA also touched the resident and a bottle of lotion before finally removing gloves, cleansing hands, and donning clean gloves. The DON, present for most of the observation, confirmed that staff should remove soiled gloves, cleanse hands, and don clean gloves when going from dirty to clean, and the CNA did not understand the breach in hand hygiene. Another resident with a history of carbapenem-resistant Acinetobacter baumannii (CRAB) and open wounds had an active order for contact isolation and a contact precautions sign posted at the room. Despite the sign instructing everyone to clean their hands before entering and when leaving, and for staff to don and discard gloves and gowns upon room entry and exit, the assistant administrator entered the room without performing hand hygiene or donning PPE, then exited and entered another room without hand hygiene. When questioned, the assistant administrator stated that if the sign was not on the resident’s door it was not active, and only after the RN checked the electronic record and confirmed the resident was on precautions for CRAB did the assistant administrator acknowledge that appropriate precautions should have been followed. Surveyors also observed a RN preparing and administering medications to multiple residents without performing hand hygiene at the start of medication preparation or before administering medications, contrary to the facility’s medication administration policy. The RN later stated that hand hygiene was usually completed between every several residents unless there were visible bodily fluids, while the DON indicated staff should complete hand hygiene prior to medication preparation and after medication administration. In addition, during multiple meal services on different units and in the main dining room, residents were not offered hand hygiene before eating. Trays did not include hand hygiene wipes, tables lacked wipes or hand sanitizer, and staff did not offer hand hygiene prior to meals. A CNA acknowledged not offering hand hygiene before breakfast and described only using a wet paper towel if hands were dirty after meals. Two residents reported they were not offered hand hygiene before or after meals but stated they would like or thought it would be a good idea to be offered hand hygiene. The dietary manager and nursing leadership confirmed that residents should be offered hand hygiene prior to meals and that hand wipes should be on room trays for all meals.
Missed IV Antibiotic Doses and Lack of Timely Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from significant medication errors, specifically missed doses of IV antibiotics for two residents with serious infections. For one resident with acute osteomyelitis, multiple stage 3 and 4 pressure ulcers, hemiplegia, and severe protein-calorie malnutrition, physician orders were in place for IV ceftriaxone once daily for two weeks and IV vancomycin for osteomyelitis. Review of the MARs showed that ceftriaxone and vancomycin were not administered on specified dates, with MAR codes indicating "other" and "hold" and references to nurse’s notes. Documentation showed that on one date the PICC line had not yet been placed and that the facility was awaiting vancomycin from the pharmacy, and on another date ceftriaxone was not available. The resident’s record did not contain evidence that the physician was notified of the missed antibiotic doses. For the second resident, who had sepsis from a soft tissue infection, right calf cellulitis and abscess, type 2 diabetes, a history of MRSA infection, and chronic lower extremity wounds, the care plan identified IV antibiotics for sepsis and cellulitis and the risk of infection related to IV/PICC use. A physician order directed IV cefazolin three times daily for infection. The MAR indicated that the order was started the day after admission, but the scheduled morning and afternoon doses were not administered. A health note later documented that the resident had missed antibiotics due to pharmacy issues. Emergency Department documentation recorded that the resident had missed three doses of IV antibiotics, and the resident expressed concern about going without antibiotics and chose to go to the ED for evaluation. Interviews with staff confirmed that delays in medication administration occurred due to pharmacy delivery and PICC line placement issues. An LPN stated that residents miss doses when medications are not delivered timely from the out-of-state pharmacy, which typically delivers nightly and can send stat medications taking approximately two hours if requested. The DON stated that medications should be administered as ordered, that non-initialed or coded MAR entries are considered not administered, and that IV medications should be started right away if available, with physician notification and documentation if there is a delay. The DON also indicated that the process is to notify the provider if a medication has not arrived so the provider can hold or change the order, but in the case of the second resident, the provider was not contacted until after multiple doses had already been missed, and the record did not show when or if the physician was notified of the missed doses. These actions and inactions resulted in multiple missed doses of ordered IV antibiotics for both residents without documented, timely physician notification.
Failure to Ensure Reliable Transportation for Baclofen Pump Services
Penalty
Summary
The deficiency involves the facility’s failure to provide reliable transportation for a resident requiring outside laboratory and surgical services for a baclofen pump change. The resident, who had paraplegia, a T1 spinal cord injury, anxiety, and depression, was cognitively intact with a BIMS score of 15/15. According to the resident’s interview, there were multiple missed or unsuccessful attempts to complete the necessary pre‑operative and surgical appointments, and the resident only reached the appointment on the fourth attempt. The resident reported that the first appointment was missed because the facility did not schedule a ride for the pre‑op visit and did not complete the required blood work, the second attempt failed because the facility did not hold the resident’s Eliquis in time, and the third attempt failed when the transportation company arrived with a car instead of a wheelchair van. Progress notes documented that a pre‑procedure physical appointment was missed due to transportation issues, and an APNP note stated that the baclofen pump replacement surgery had been delayed multiple times due to transportation problems. Staff interviews further confirmed issues with transportation coordination and reliability. Transportation staff reported using several different transportation companies and were unaware of the specific transportation failures for this resident, and could not explain what happened with at least one missed appointment, noting that another former transportation staff member might have kept notes elsewhere. A RN acknowledged there had been a few missed appointments recently and confirmed that at least one of this resident’s appointments was missed when the ride did not show up, despite the resident being ready. The DON confirmed there were issues with a transportation company, and the NHA stated that transportation scheduling and approval processes were in place, including a binder and electronic dashboard for appointments, but staff education for the updated transportation process was not provided to the surveyor when requested.
Failure to Submit Final Abuse Investigation Report Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to submit the final results of an abuse investigation to the State Agency (SA) within the required five working days. The facility’s Abuse/Neglect/Exploitation policy states that the Administrator will confirm the initial report was received and report the results of the investigation to government agencies within five working days of the incident, as required by state agencies. For one resident, R4, the facility submitted an initial allegation of abuse to the SA on 11/22/25 following a reported concern involving possible illicit substances provided by a family member. The final investigative report, documented on the facility’s Misconduct Incident Report, was not completed and submitted until 12/3/25 at 1:55 PM by the Chief Nursing Officer, which exceeded the required timeframe. R4’s admission record showed that R4 had been admitted earlier in the month, and the admission MDS with an ARD of 11/16/25 documented a BIMS score of 15/15, indicating intact cognition. The incident prompting the abuse allegation occurred after a family visit on 11/22/25, during which R4 exhibited a significant escalation in behavior, and a family member reported that another family member may have previously provided R4 with illicit substances. Staff interviews confirmed that the facility understood the requirement to submit the final investigative report within five working days of the initial report, with the CNO stating the report was due on 11/28/25 and the Administrator stating it was due on 12/1/25. Both acknowledged that the final report was not submitted to the SA within the required timeframe.
Failure to Maintain Adequate Resident Care Supplies
Penalty
Summary
The facility failed to ensure sufficient supplies of personal care items, including briefs, wipes, and wash cloths, for residents. One resident, who was dependent on staff for toileting and required partial to moderate assistance with hygiene, reported that the facility frequently ran out of the correct size briefs, resulting in staff having to use two different briefs to make one. The same resident also stated that the facility ran out of wipes, and staff did not cleanse the resident during changes on multiple occasions since admission. Staff interviews confirmed that supply shortages were a recurring issue, with supplies often depleted by the end of the week and residents complaining about the lack of necessary items. Additional staff, including an LPN and a CNA, corroborated that the facility regularly ran out of briefs, wipes, and wash cloths, and that the issue had persisted especially after the departure of the previous supply clerk. The central supply clerk, who had been in the position for a month and a half, indicated that supply orders were based on estimates from the previous week and census, and acknowledged that the facility had run out of supplies before. The nursing home administrator confirmed that supplies were ordered weekly and was aware of a recent shortage of wipes, but was not aware of shortages of briefs or incorrect sizes. No policy related to supplies was provided during the survey.
Failure to Ensure Resident Privacy During Care Due to Visitor Presence
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for toileting, transfers, dressing, and hygiene reported a lack of privacy during personal care in a double occupancy room. The resident, who had intact cognition and multiple medical diagnoses including muscle wasting, osteoarthritis, pain syndrome, and mental health disorders, expressed discomfort with a male visitor being present in the room while care was provided. The resident observed the male visitor retrieving items from a refrigerator during these times, which made the resident uncomfortable, and communicated this concern to nursing staff. Interviews with staff confirmed awareness of the resident's discomfort, but there was no facility policy regarding visitors in the room during care. Staff indicated that if a resident reported a concern, they could ask the visitor to step out, but this was not consistently enforced. The facility administrator acknowledged knowledge of the situation but did not follow up with other residents to identify similar concerns or provide staff education to prevent recurrence. The lack of a clear policy and consistent practice led to inadequate privacy for the resident during care.
Failure to Maintain Sterile Technique and Hand Hygiene During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not receive respiratory care consistent with professional standards of practice. The facility's policy required aseptic technique and sterile gloves during tracheostomy care, as well as adherence to hand hygiene protocols. During an observed tracheostomy care procedure, an LPN failed to maintain sterile technique and did not follow proper hand hygiene practices at multiple points throughout the procedure. The LPN placed tracheostomy care supplies on an unclean bedside table that contained used cups, dried sticky material, and an empty urinal, without cleaning the surface beforehand. The LPN handled sterile items with non-sterile gloves, contaminating the sterile kit, and placed sterile gloves and other items on the unclean table. The LPN also used a bottle of normal saline that was not sterile and failed to establish a sterile field for the procedure. Throughout the process, the LPN repeatedly failed to perform hand hygiene after removing gloves, as required by facility policy and CDC guidelines. Additionally, the LPN did not check the resident's neck for skin breakdown from the tracheostomy necktie during the procedure, despite indicating that this should be part of the care. The Director of Nursing confirmed that the expected standard of practice was not followed, including cleaning the work area, maintaining sterility, and performing hand hygiene at appropriate times.
Failure to Follow Infection Control Protocols During Peri-Care
Penalty
Summary
During the provision of peri-care for one resident, two Certified Nursing Assistants (CNAs) failed to adhere to proper infection prevention and control protocols as outlined in the facility's policy. The CNAs donned gowns and gloves before entering the resident's room and proceeded to provide care, including washing the resident's underarms, breasts, and peri-area, as well as handling soiled linens and briefs. Throughout the care process, the CNAs repeatedly touched the resident and various items in the room with soiled gloves, including after cleaning areas contaminated with stool. They did not change gloves or perform hand hygiene between tasks as required by standard precautions and the facility's infection control policy. The resident involved was dependent on staff for toileting and required partial to moderate assistance with hygiene, but had intact cognition as indicated by a BIMS score of 15 out of 15. The CNAs themselves confirmed during an interview that they had touched the resident and multiple items in the room with soiled gloves and acknowledged that they should have changed gloves and washed hands after providing peri-care. The facility's infection prevention and control policy required hand hygiene and appropriate use of personal protective equipment, but a specific hand hygiene policy was not provided during the survey.
Failure to Convey Resident Funds Post-Discharge
Penalty
Summary
The facility failed to ensure the timely conveyance of a resident's personal funds following discharge, as required by state law. A resident, who was a private payee, was discharged from the facility but did not receive a final accounting or refund of the remaining balance in their trust account within the mandated 30-day period. The resident's Health Care Power of Attorney (HCPOA) reported not receiving any accounting of the trust account or the remaining balance, which amounted to $2520.00. The Business Office Manager, who was not employed at the facility during the resident's stay, confirmed the oversight. The Nursing Home Administrator acknowledged that attempts were made to send a reimbursement check, but it was returned due to an incorrect mailing address. Despite multiple contacts from the resident's representative, the facility did not rectify the situation in a timely manner, resulting in a deficiency related to the management of resident funds post-discharge.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility was found to have significant deficiencies in its infection prevention and control program, particularly in managing a COVID-19 outbreak. Staff were observed entering and exiting COVID-positive rooms without wearing the appropriate personal protective equipment (PPE), such as N95 masks and eye protection, despite clear signage indicating the required PPE. Additionally, staff were seen doffing PPE in hallways instead of inside the rooms, which increases the risk of contamination. There were also instances where staff worked with COVID symptoms without being tested, and COVID-positive residents were not adequately isolated from non-COVID residents, as evidenced by shared smoking areas and improper use of privacy curtains. The facility failed to implement effective infection control measures during the outbreak. This included not using dedicated equipment for COVID-positive residents, allowing food carts to be left open near COVID-positive rooms, and not ensuring that residents were offered the most recent COVID-19 vaccine or antiviral medications. Staff were also observed not adhering to proper hand hygiene practices during wound care and medication administration, further compromising infection control efforts. The facility's water management control measures were also lacking documentation, with testing and documentation of these measures not being completed since the departure of a full-time Maintenance Director. This gap in documentation and oversight further highlights the facility's inadequate infection control practices, contributing to the widespread potential for harm to residents and staff during the COVID-19 outbreak.
Removal Plan
- A record review was completed on all residents to ensure no unreported signs and symptoms of infection were present.
- An audit was completed on all residents COVID-19 vaccination status with vaccines offered if appropriate.
- All staff had a competency completed on DONNing and DOFFing PPE as well as hand hygiene.
- All staff were educated on the appropriate use of PPE on all types of precautions and COVID specific precautions to include donning gown, gloves, mask, and eye protection when entering COVID positive rooms, and removing PPE prior to leaving the resident room.
- Education also included not wearing a surgical mask under a N95 and that surgical masks are to be worn in the halls during a COVID outbreak.
- All staff were educated on appropriate hand hygiene.
- All nursing staff were educated on offering Antiviral medications for residents with a positive COVID result and offering the most recent COVID vaccines.
- All staff were educated on the use of privacy curtains in positive COVID rooms as well as disinfecting equipment and doffing PPE after working with a COVID positive resident.
- All staff were educated on taking COVID positive smoking residents out separately than non-positive smoking residents.
- All staff were educated on dining carts cannot be left open during meal tray pass in the hallways.
- All staff were educated on testing for COVID prior to working if symptoms are present.
- Infection Control and vaccines policy and procedures were reviewed with no updates.
- DON or designee will audit residents to ensure residents are up to date with current COVID-19 vaccinations.
- DON or designee will audit employees to ensure appropriate DONNing/DOFFing PPE, privacy curtains are being closed in a COVID positive room and appropriate hand hygiene is being completed.
- Dietary Manager or designee will complete observations to ensure dining carts are being closed during meal tray pass in the hallways.
- SSD or designee will complete observations to ensure COVID positive residents are being taken out after non COVID residents have finished smoking.
- Audits will be reported and reviewed to QAPI for further direction.
Failure in Midline Catheter Management Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure the safe administration and management of a midline catheter for a resident, leading to a serious deficiency. The resident, who was readmitted to the facility with a midline for IV antibiotic treatment following a diagnosis of sepsis secondary to a urinary tract infection, experienced complications when the midline could not be flushed properly. Despite the LPN reporting the issue to an RN, there was a significant delay in assessing the problem, and the RN attempted to remove the catheter without a physician's order, resulting in the catheter breaking and a piece being retained in the resident's arm. The facility's policies on intravenous therapy and midline catheter management were not followed, as evidenced by the lack of timely assessment, failure to notify the provider, and improper removal procedures. The resident was sent to the emergency room nine hours after the initial concern was raised, where it was confirmed that a 10 cm length of catheter was retained in the resident's arm, requiring surgical intervention. The facility also failed to document monitoring of the midline site, measure and record the catheter length, and ensure staff competency in managing such devices. Interviews with staff revealed gaps in training and competency checks related to midline care, with several staff members indicating they had not received adequate education or competency assessments. The facility's documentation was inconsistent, with missing records of orders, assessments, and competency checks. This deficiency placed the resident at risk for serious complications, including pulmonary embolism, stroke, or death, and was identified as an Immediate Jeopardy situation.
Failure to Properly Explain Arbitration Agreements
Penalty
Summary
The facility failed to implement a process to assess residents' cognitive ability to understand an arbitration agreement before obtaining their signatures. This deficiency was identified during interviews and record reviews, where it was found that the staff responsible for explaining the arbitration agreement lacked a complete understanding of it. As a result, they were unable to thoroughly explain the agreement to residents or their representatives, leading to a lack of understanding among the residents about the implications of signing the agreement. Several residents and their representatives, including R25, R12, R128, R129, and R72's representative, expressed concerns about not fully understanding the arbitration agreement they signed upon admission. Some residents indicated they wanted to revoke their agreements, as they were unaware that signing the agreement meant forfeiting their constitutional rights to use the judicial system for dispute resolution. The facility's policy stated that arbitration agreements were not a condition for admission, but this was not effectively communicated to the residents. The Admissions Coordinator, responsible for explaining the arbitration agreement, demonstrated a lack of understanding of the agreement's implications. During an interview, the coordinator was unable to explain that signing the agreement meant giving up the right to a jury or court trial. Furthermore, the coordinator was unsure about the timeframe within which residents could revoke the agreement. This lack of knowledge and communication contributed to the residents' misunderstanding and dissatisfaction with the arbitration process.
Inadequate Supervision in Charging Electric Wheelchairs
Penalty
Summary
The facility failed to ensure that residents received adequate supervision to prevent accidents related to the charging of electric wheelchairs. Observations and interviews revealed that electric wheelchairs were being charged in residents' rooms, contrary to the facility's policy. This policy, implemented on March 8, 2020, mandates that electric wheelchairs should be charged in an area not used by residents for sleeping and without oxygen in the vicinity due to the potential for fire or explosion. Despite this, surveyors observed multiple instances where electric wheelchairs were plugged in and charging in residents' rooms, including those of residents with specific mobility needs such as Multiple Sclerosis. Interviews with staff, including CNAs, LPNs, and the Director of Nursing, indicated a lack of awareness or adherence to the policy. Several staff members, including CNAs and a COTA, stated that they charged the wheelchairs in residents' rooms, and some were unsure of the correct procedure. The Director of Nursing and the Interim Nursing Home Administrator both acknowledged that wheelchairs should not be charged in resident rooms and should be behind a fire-safe door. This discrepancy between policy and practice led to the deficiency being identified by the surveyors.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that residents received food at a palatable temperature, as evidenced by observations and resident interviews. During a survey, it was noted that hot foods were served cold and cold foods were served warm on one of the hallways and during a test tray evaluation. Specifically, a meal tray requested by the surveyor showed pork with gravy at 114.2°F, potatoes at 124.7°F, and red juice at 50.1°F, all of which were outside the facility's policy requirements for food temperatures. The Dietary Manager acknowledged the issue and mentioned that the facility had bottom plates to maintain food temperature, but they were not in use because they made it difficult for residents to eat in bed. Two residents, both with a BIMS score of 15 indicating cognitive intactness, expressed concerns about receiving cold food. One resident reported during an interview that their meal trays were cold upon delivery to their room. The facility's policy on food temperatures was not dated, but it stated that hot foods should be held at 135 degrees or greater, and no food should be served that does not meet the food code standard temperatures. The Dietary Manager indicated that food temperatures depend on personal preference, but acknowledged the residents' complaints and the surveyor's findings.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for a resident. The resident, who was cognitively intact with a BIMS score of 15, was observed with multiple medications, including Restasis eye drops and nasal sprays, on their bedside table. The facility's policy requires an interdisciplinary team assessment to determine if a resident can safely self-administer medications, and this assessment must be completed before self-administration begins. However, the assessment for this resident was completed after the surveyor observed the medications at the bedside and after the RN confirmed that the resident was self-administering the eye drops. Additionally, the facility policy mandates that medications for self-administration be stored securely, typically in a locked drawer or lock box, to prevent access by other residents. During the survey, it was noted that the medications were not stored in a lockable manner, as they were simply placed on the bedside table without any secure storage. The DON confirmed that the assessment should be completed prior to self-administration and that medications should be stored in a locked drawer or lock box, which was not the case for this resident.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their records. One resident was admitted for short-term rehabilitation following a fall and was discharged home to the community. However, the MDS inaccurately indicated that the resident was deceased upon discharge. This error was identified during a review of the MDS section A, where the Director of Nursing and Corporate RN confirmed the mistake. Another resident, with diagnoses including post-traumatic stress disorder and dementia, had a quarterly MDS that failed to reflect a gradual dose reduction (GDR) of Risperdal, which had been reduced from four times a day to three times a day. The MDS inaccurately marked that no GDR had been attempted, and the date of the last attempted GDR was left unanswered. This discrepancy was acknowledged by the Director of Nursing during an interview, who noted that the MDS should have been completed correctly to include the GDR.
Failure to Conduct Timely AIMS Testing for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications, specifically concerning the administration of psychotropic drugs. The facility's policy requires that psychotropic drugs are only given when necessary to treat a specific condition, with documented benefits and regular monitoring of the resident's response. The policy also mandates that residents receiving antipsychotic medications undergo an Abnormal Involuntary Movement Scale (AIMS) test upon admission, quarterly, and with any significant changes in condition or medication. However, for one resident, identified as R10, who was prescribed Risperdal for mood disturbance related to dementia, the AIMS test was not conducted as per the policy requirements. R10 was admitted with diagnoses including post-traumatic stress disorder, dementia with psychotic disturbance, and anxiety disorder. Despite being on an antipsychotic medication, R10's last AIMS test was conducted over a year ago, missing at least three quarterly assessments. During an interview, the Director of Nursing acknowledged that the AIMS test for R10 was not completed according to the facility's policy, indicating a lapse in adherence to the established protocol for monitoring the effects of psychotropic medications.
Medication Error Due to Improper Insulin Pen Use
Penalty
Summary
The facility was found to have a medication error rate of 6.45%, exceeding the acceptable threshold of 5%. This was due to two errors out of 31 opportunities during a medication pass task, affecting one out of three residents. Specifically, LPN N failed to prime the insulin pens before administering insulin to a resident with Type 2 Diabetes Mellitus. The facility's policy on medication administration did not include instructions on priming insulin pens, although the manufacturer's guidelines for the Fiasp insulin pen clearly state the necessity of priming to ensure the correct dose is delivered. During the survey, LPN N was observed preparing insulin pens for administration without priming them, despite being questioned by the surveyor about the necessity of this step. The Director of Nursing confirmed that the procedure for administering insulin via pen includes priming the pen after verifying the order and checking blood sugar levels. The failure to prime the insulin pens as per the manufacturer's instructions and the facility's oversight in not including this step in their policy contributed to the medication error rate exceeding the acceptable limit.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the omission of prescribed medications. The resident, who was admitted with conditions including type 2 diabetes mellitus and hypertension, did not receive two doses of insulin and four doses of Metoprolol Tartrate over two days. The Medication Administration Record (MAR) showed blank spaces for these medications, indicating they were not administered as ordered. The resident confirmed to the surveyor that he did not receive his insulin during his first two days at the facility. Interviews with the facility's nursing staff revealed a lack of adherence to medication administration protocols. The Director of Nursing (DON) acknowledged that the medication orders were not transcribed correctly into the electronic medical record, which led to the omission. The DON also confirmed that the medications should have been administered according to the physician's orders. Despite identifying the error and providing verbal education to the responsible LPN, the DON did not extend this education to all nursing staff to prevent recurrence.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that their antibiotic stewardship program, which includes antibiotic use protocols and a system to monitor antibiotic use, was effectively implemented for two residents. Resident R64 was treated with an antibiotic for cellulitis despite not meeting the facility's standard of practice, as defined by the McGeer Criteria. The criteria require the presence of pus or at least four specific symptoms, but R64 only exhibited warmth, redness, and swelling, which did not meet the minimum criteria. The facility's documentation did not clearly link R64's pain levels to the cellulitis encounter, further indicating a lack of adherence to the established protocols. Similarly, Resident R35 was treated with antibiotics for pneumonia without meeting the necessary criteria. According to the McGeer Criteria, a chest x-ray demonstrating pneumonia or a new infiltrate is required, along with at least one constitutional criterion and one respiratory sub-criterion. However, R35's documentation lacked a chest x-ray at the time of diagnosis and did not provide evidence of meeting the constitutional criteria. The chest x-ray provided from a previous date showed conditions not indicative of pneumonia, such as cardiomegaly and pleural effusion, which were not relevant to the current diagnosis. The surveyor's interviews with the LPN/Infection Preventionist confirmed that the symptoms for both residents did not meet the McGeer Criteria, indicating a failure in the facility's antibiotic stewardship program. The facility's policy required nursing staff to assess suspected infections using an SBAR form and adhere to laboratory testing standards, but these protocols were not followed, leading to inappropriate antibiotic use for both residents.
Resident Dignity and Assistance Deficiency
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, specifically in the case of a resident identified as R5. R5, who is cognitively intact with a BIMS score of 15, expressed concerns about not being assisted out of bed after using the bedpan. Despite her requests, staff often told her to remain in bed for the rest of the day, making her feel infantilized. This issue was reported to various staff members, including a Registered Nurse, Certified Nursing Assistants, and a Licensed Practical Nurse, all of whom acknowledged the resident's right to be assisted back up if she wished. R5's care plan indicated she required assistance with personal care due to physical limitations from a stroke and other medical conditions. The staff's failure to assist her in getting out of bed after using the bedpan, particularly around the time of shift changes, was a recurring issue. This lack of assistance was contrary to the facility's expectations and the resident's rights, as confirmed by the Nursing Home Administrator and the Director of Social Services, who acknowledged the need to respect the resident's preferences and dignity.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure grievances were documented and thoroughly resolved for two residents, R5 and R29. R5, who has a history of stroke, anxiety disorder, major depressive disorder, and other conditions, expressed concerns about staff not assisting her in getting back up after using the bedpan. Despite being cognitively intact, R5 felt infantilized by the staff's refusal to help her, with staff reportedly saying, "We aren't playing the up and down game." Multiple staff members, including RN V, CNA Z, and CNA Y, acknowledged R5's concerns but did not assist her in filing a grievance. The facility's grievance policy requires prompt resolution and documentation of grievances, which was not followed in R5's case. R29, who is also cognitively intact and dependent on staff for toileting, filed a grievance after being left on the commode for an extended period. The grievance log from October 2024 showed an incomplete entry for R29's grievance, with no resolution or notification date listed. Interviews with staff, including DSS W and NHA A, revealed that the grievance process was not properly followed, as R29 was not informed of the outcome. The investigation into R29's grievance confirmed a wait time of 20-30 minutes, but the documentation was only completed after the surveyor's inquiry. The facility's failure to document and resolve grievances as per their policy resulted in deficiencies in handling the concerns of R5 and R29. The staff's acknowledgment of the grievances without proper documentation and follow-up highlights a breakdown in the grievance process. The facility's policy mandates that grievances be promptly resolved and documented, keeping residents informed throughout the process, which was not adhered to in these cases.
Failure to Monitor Pacemaker and Daily Weights
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards of practice for two residents. The first resident, who has a cardiac pacemaker, had their Medtronic monitoring system unplugged, preventing timely data transmission to the cardiac clinic. This issue was observed by the surveyor and confirmed by interviews with the resident and multiple staff members, including registered nurses and the nursing home administrator. The care plan for this resident did not include goals or interventions related to the Medtronic, and there was no physician order found for the device, leading to a lack of proper monitoring for potential cardiac events. The second resident, who has a history of congestive heart failure, was not weighed daily as per the physician's order. The resident's daily weight records showed missing entries for nine days in October. Interviews with nursing staff revealed that the resident often refused to be weighed due to family visits, and the staff sometimes forgot to return to complete the task. The Director of Nursing acknowledged the expectation for daily weights and the need for documentation if a resident refuses, indicating a lapse in communication and adherence to the weight monitoring schedule.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional principles, affecting two medication rooms, one medication cart, and one resident who self-administers medication. Surveyors observed an insulin pen without labeling, a vial of Tuberculin solution without an open or expiration date, and several expired medications including liquid Tylenol, Enulose, and Gerimox. These observations indicate a lack of adherence to the facility's policy on medication labeling and storage. In one instance, a medication cart contained an unlabeled Fiasp insulin pen, which lacked a resident name and open date. An LPN confirmed that the pen should have been labeled with the resident's name and open date. Additionally, the medication rooms contained expired medications and a Tuberculin vial without an open date, which were not in compliance with the facility's policy. The Director of Nursing explained that central supply staff is responsible for stocking and checking expiration dates, but the process was not followed correctly. A resident, identified as R32, was observed with medication stored in an unlocked drawer at their bedside. The resident, who is cognitively intact, stated that the medication had never been locked for safety. The facility's policy requires that self-administered medications be stored securely, but this was not adhered to in R32's case. The Director of Nursing confirmed that self-administered medications should be stored in a locked drawer or lock box, which was not done for R32.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to ensure that a resident, identified as R1, received appropriate care to prevent and treat pressure injuries (PIs) according to professional standards of practice. R1 was admitted without any pressure injuries but was at risk for their development due to various health conditions, including chronic kidney disease, muscle wasting, and chronic congestive heart failure. Despite being at moderate risk for PI development, as indicated by the Braden Scale, the facility did not implement aggressive measures to prevent the development of a PI, which resulted in R1 developing an unstageable pressure injury. The facility's policy on pressure injury prevention was not followed, as evidenced by the lack of timely repositioning and inadequate use of pressure-relieving devices. R1's care plan was not updated to reflect the presence of the pressure injury or to include new interventions and goals to promote healing. Despite recommendations from a wound care specialist to upgrade R1's mattress and chair cushion, these changes were not implemented, and R1 remained on the same foam mattress throughout his stay. Additionally, there were multiple grievances filed by R1's wife regarding long wait times for assistance, which contributed to R1 being left in soiled briefs for extended periods. Interviews with staff and resident representatives revealed that R1 often waited long periods for assistance with repositioning and incontinence care. The Director of Nursing acknowledged that R1's care plan should have been updated with new interventions when the pressure injury was noted. The facility's failure to adhere to its own policies and physician recommendations resulted in inadequate care for R1, leading to the development and progression of a pressure injury.
Failure to Recognize and Respond to Resident's Respiratory Distress
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice when a resident experienced a change in condition. The resident, who had a history of chronic respiratory failure with hypoxia and COPD, exhibited shortness of breath and critically low oxygenation levels. Despite these symptoms, the LPN did not recognize the situation as a medical emergency, did not perform a comprehensive cardiorespiratory assessment, and failed to consult with an RN, leading to a delay in treatment. The resident's condition deteriorated over a period of approximately 1.5 hours, during which time the LPN attempted to manage the situation by increasing oxygen levels and administering a nebulizer treatment. However, the LPN did not notify the provider or call emergency services promptly, despite the resident's oxygen saturation levels being critically low. The LPN's actions included using an oxygen mask with insufficient flow, which may have exacerbated the resident's respiratory distress. Emergency services were eventually called, but by the time they arrived, the resident's condition had worsened significantly. The resident was transported to the hospital, where they were pronounced dead shortly after arrival. The delay in recognizing the severity of the resident's condition and the failure to take immediate and appropriate action contributed to the adverse outcome.
Removal Plan
- Investigation initiated.
- Police notified.
- Nurse suspended.
- Chart review completed.
- Hospital notes reviewed.
- Staff statements obtained.
- Like resident statements obtained.
- Skin assessments completed on residents with BIMS of 12 or less.
- Audit completed on all change in conditions to ensure RN assessment completed and Nurse Practitioner was updated.
- Audit completed on oxygen use orders.
- Audit completed on all vital signs to determine if there were any missed vital signs or abnormal vital signs.
- Review of all nursing competencies.
- Review of crash carts.
- Audit of Code status.
- Audits for change in condition, appropriate assessments, vital signs completed, any new orders completed, placed on 24-hour board, and continued follow up.
- Respiratory assessments reviewed or completed on residents with Respiratory diagnosis.
- Clinical Consulting educated the QAPI committee on notifications/investigations that must begin for any death or unusual event.
- Education completed for all licensed staff and CNA's.
- Recognition of change in condition with post test O2 orders with post test.
- Following MD orders and MD notification.
- MD and RN notification.
- Vital signs and Baseline vital signs with post test.
- Education completed for all staff.
- Change in condition.
- Reporting to nursing any changes.
- Abuse, Neglect, Misappropriation.
Failure to Maintain Safe Environment and Update Care Plans
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not ensure that resident care plans were up to date, as evidenced by the case of a resident (R3) who experienced multiple falls. R3, a short-term rehab resident with a history of falls and various medical conditions, including MRSA, type 2 diabetes, and cognitive communication deficit, was at high risk for falls. Despite this, the facility did not promptly update R3's care plan with necessary interventions following each fall, leading to repeated incidents. R3's fall risk evaluations consistently indicated a high risk for falls, yet the care plan updates were delayed. For instance, after a fall on May 9, 2024, the intervention to hang a sign in the resident's room and bathroom to remind them to call for assistance was only added to the care plan six days later. Similarly, after a fall on May 15, 2024, the intervention to offer assistance with toileting every two hours while awake was added five days later. Furthermore, after a fall on June 1, 2024, the intervention to offer toileting assistance following lunch was added 16 days later. Additionally, there were discrepancies between the care plan and the CNA care plan, with some interventions not being communicated to the CNAs. For example, the intervention to use a larger Dycem on the wheelchair seat was not added to the care plan, and CNAs were unaware of certain fall interventions, such as toileting assistance. The lack of consistent communication and timely updates to the care plan contributed to the resident's repeated falls and injuries, including a laceration under the left eye that required stitches.
Failure to Maintain Continence in Residents
Penalty
Summary
The facility failed to assess and provide appropriate treatment and services to maintain or restore bowel and bladder continence for two residents, resulting in a decline in their continence status. Resident R4, who was continent of bowel and bladder prior to admission, experienced a decline in continence shortly after admission. The facility did not implement measures to improve R4's continence, such as a toileting program or updating the care plan, despite R4's frequent incontinence episodes. R4 expressed feelings of degradation and embarrassment due to the lack of timely assistance and the need to remain in soiled clothing. Resident R2 also experienced a decline in continence after admission, transitioning from continent to frequently incontinent of bowel and bladder. The facility did not update R2's care plan or establish a toileting program to address this decline. Observations revealed that R2 was left in soiled conditions for extended periods, leading to frustration and a desire to leave the facility. Interviews with staff indicated a lack of awareness and communication regarding R2's continence status and the absence of a bowel and bladder diary or training program. The facility's policies on incontinence and comprehensive care planning were not followed, as evidenced by the lack of person-centered goals and interventions in the care plans of both residents. The Director of Nursing confirmed that bowel and bladder assessments were not completed for R4 and R2, and the CNA Kardex lacked detailed information on how to assist the residents with toileting. This failure to implement a robust care plan and conduct ongoing assessments resulted in the residents' functional decline in continence status.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, affecting all 72 residents across four halls. Residents R5, R7, R9, R4, and R2 expressed concerns about inadequate staffing, which led to long wait times for call lights and unmet basic needs. R5 reported waiting over an hour for assistance, while R7 described being left in soiled conditions for extended periods. R9 also experienced delays in receiving help with activities of daily living, indicating that staff were overwhelmed and unable to attend to all tasks. Staff members corroborated these concerns, acknowledging that they were unable to complete all necessary tasks due to insufficient staffing. CNA O mentioned that she could not assist all residents with personal hygiene, while Scheduler P and DON B recognized the staffing issues and the unacceptable wait times for call lights. Despite understanding the problem, the facility's staffing was based on census rather than the actual needs of the residents, leading to significant delays in care. The deficiency was further highlighted by the experiences of R4 and R2, who both required extensive assistance with personal hygiene and mobility. R4 reported waiting 1-2 hours for assistance, often sitting in wetness due to incontinence. R2 was found in a soiled state, having waited over an hour for help. Staff members, including CNAs G, H, I, F, and J, consistently reported being short-staffed, which hindered their ability to provide timely care and led to resident frustration. Despite raising these concerns with management, no resolution had been reached, and the staffing issues persisted.
Resident's Dignity Compromised Due to Lack of Clean Clothes
Penalty
Summary
The facility failed to ensure a dignified existence and self-determination for a resident, identified as R4, who was admitted with multiple diagnoses including Chronic Kidney Disease, Type II Diabetes with Diabetic Neuropathy, and Major Depressive Disorder. R4, who was cognitively intact, expressed concerns about being forced to wear a nightgown due to a lack of clean clothes, which made her uncomfortable and led to her isolation in her room. The resident reported feeling embarrassed and foolish, stating that she avoided communal areas and activities because she did not have appropriate clothing. Observations and interviews conducted by the surveyor revealed that R4 had no clean clothes available on one occasion, and later had clean clothes, which improved her willingness to participate in activities. Staff members confirmed that R4 mostly stayed in her room and was embarrassed about not having clothes to wear. The facility's failure to provide clean clothes and honor R4's choice to dress in her own clothes resulted in her embarrassment, loss of dignity, and social isolation.
Financial Mismanagement Leads to Service Disruptions
Penalty
Summary
The Bedrock Corporation's governing body failed to ensure adequate funds were available for the safe and efficient management of the facility, affecting all 72 residents. The corporation did not maintain current payment status with several service providers and vendors, leading to potential disruptions in essential services. The facility's pharmacy provider, Alixa Pharmacy, terminated its services due to unpaid invoices, and the account is currently in litigation. Additionally, the facility owes significant amounts to other vendors, including Sysco, Synapse Health, Point Click Care, Twinmed, Comprehensive Therapy Specialist, and We-Energies, with some accounts being overdue by more than 150 days. The facility's financial mismanagement extended to delinquent property taxes and utilities, with outstanding amounts for 2022 and 2023. The Wisconsin Division of Medicaid Service reported a substantial unpaid bed tax assessment, and the facility also owes federal Civil Money Penalties. The corporation's failure to maintain financial obligations has resulted in notices of service disruption and potential disconnection of utilities, which could severely impact the quality of care and life for the residents. Interviews with various accounts payable representatives and vendors revealed ongoing issues with communication and payment resolutions. The facility owner acknowledged the financial difficulties and stated efforts were being made to address the outstanding debts. However, the lack of timely payments and unresolved financial obligations continue to pose a risk to the facility's operations and the well-being of its residents.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was clinically assessed for the appropriateness of self-administering medications. The resident, who was observed with medications at her bedside, had not undergone a self-administration assessment as required by the facility's policy. The policy mandates that an interdisciplinary team should evaluate the resident's capability to self-administer medications safely, considering factors such as the resident's ability to follow directions and store medications securely. However, no such assessment was documented for the resident, and there was no physician's order permitting self-administration. The resident in question had a history of significant medical and psychological issues, including encephalopathy, major depressive disorder, and a recent intentional overdose with prescription medications. Despite being cognitively intact according to her Minimum Data Set (MDS), she was dependent on staff for various activities of daily living and mobility. Her hospital discharge summary highlighted a history of intentional overdose with medications, and her care plan identified her as at risk for alterations in psychosocial well-being due to suicidal ideations and recent intentional overdose. Interviews with facility staff, including CNAs and an LPN, revealed that medications were frequently left at the resident's bedside, despite her history of overdose and the absence of a self-administration assessment. The Director of Nursing confirmed that the facility conducts self-administration assessments only upon request and acknowledged that it was not safe for the resident to have medications at her bedside. This oversight in following the facility's policy and ensuring the resident's safety led to the deficiency identified by the surveyor.
Failure to Honor Residents' Right to Choose Physician
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, as evidenced by the experiences of two residents. One resident, who was cognitively intact, expressed concerns about not being allowed to see her primary care physician and was instead required to see the in-house physician and nurse practitioner. This resident also reported that her medication for food digestion was discontinued by the in-house physician, and she was not informed about the option to choose her own physician. The Director of Nursing was unaware of these concerns and stated that residents could see any provider they wished. Another resident, also cognitively intact, was not aware of her right to choose her physician and had all her physician orders signed by the facility's medical director. This resident missed a nephrology appointment due to a scheduling error and lack of assistance from the staff, and the appointment was not rescheduled. An anonymous complainant reported communication difficulties with this resident and mentioned that she missed a primary care appointment because she was not informed about it.
Inadequate Supervision and Medication Management for Resident with Self-Harm History
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who was admitted following an intentional overdose with Potassium and Amlodipine. Despite the resident's history of intentional self-harm and the absence of a self-administration of medication assessment, staff allowed the resident to have unsupervised access to these medications. The facility's policy on accidents and supervision requires identifying hazards and risks, evaluating and analyzing them, and implementing interventions to reduce them, but these steps were not adequately followed for this resident. The resident, who was cognitively intact with a BIMS score of 13 out of 15, had a history of major depressive disorder, suicidal ideations, and a recent intentional overdose. The hospital discharge summary recommended stopping the use of Amlodipine and Potassium, yet the resident's physician orders included these medications. The resident's care plan focused on psychosocial well-being and depression but lacked specific interventions for safety precautions or supervision to prevent self-harm behaviors. During the survey, it was observed that the resident had medications left at her bedside without supervision, which was confirmed by interviews with staff members. The LPN and DON acknowledged that the resident should not have medications left unsupervised due to her medical history. Despite this, the facility did not conduct a self-administration of medication assessment for the resident, and staff continued to leave medications at her bedside, indicating a failure to adhere to the facility's policy and ensure the resident's safety.
Failure to Follow Tornado Safety Procedures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents during a tornado warning, as evidenced by the experiences of four residents. The facility's policy required staff to relocate residents to designated safe areas, close doors, and provide protective items like pillows and blankets. However, during the tornado warning, staff did not follow these procedures, leaving residents in potentially hazardous situations. Resident 1, who is cognitively intact but dependent on staff for transfers, reported that she was left in her room during the tornado warning, watching the storm through the window without any protective measures taken by the staff. Similarly, Resident 2, who requires a Hoyer lift for transfers, was not moved to a safe area, and no additional protective measures were provided. Resident 3, who is independent with transfers but requires assistance with dressing, also reported that no efforts were made to move him to a safer location or provide protection from debris. Interviews with staff revealed a lack of understanding and adherence to the facility's emergency procedures. Several staff members, including CNAs and LPNs, reported inconsistent actions during the tornado warning, such as closing blinds and doors but not relocating residents to hallways or providing protective items. The Director of Nursing confirmed that the expected procedures were not followed, indicating a breakdown in communication and training regarding emergency preparedness.
Failure to Protect Resident from Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with moderate cognitive impairment and multiple health conditions, including encephalopathy and congestive heart failure, who was dependent on staff for daily care. The resident had a verbal altercation with a CNA over a door being left open, which led to the CNA becoming upset and perseverating on the incident. The CNA subsequently wrote a threatening letter to the resident, stating intentions to kill him and using derogatory language. The letter was discovered by the resident, who then showed it to another CNA. This CNA reported the note to a Licensed Practical Nurse (LPN), who escalated it to the Director of Nursing (DON). The facility initiated an investigation, during which multiple staff members provided statements about the CNA's behavior and the incident. The CNA initially denied writing the letter but later confessed after being questioned and bringing in her personal laptop, which appeared to have been wiped. The CNA admitted to writing the letter at a library and expressed remorse for her actions. The facility's failure to prevent this abuse resulted in a finding of Immediate Jeopardy, indicating a serious threat to the resident's safety and well-being.
Removal Plan
- Initiated investigation.
- Trauma assessment completed for R1.
- PHQ9 assessment for R1.
- Completed a new BIMS for R1.
- Abuse Policy education to all staff.
- R1's care plan was updated.
- Placed R1 on checks.
- R1 was placed on the board to monitor psychosocial well-being.
- Interviewed residents and staff regarding abuse.
- Complete skin checks on residents who were not able to be interviewed.
- Suspended alleged employee.
- Education to all staff to notify management if they have a concern regarding staff burnout.
Failure to Report Alleged Abuse Incident to State Agency
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident and a Certified Nursing Assistant (CNA) to the State Agency within the required timeframe. The incident involved a life-threatening note left by the CNA for the resident, which contained derogatory and threatening language. Despite initiating an investigation and involving the police, the facility did not report the incident to the State Agency as required by their policy. The resident involved had a history of encephalopathy, type 2 diabetes mellitus, hallucinations, and congestive heart failure, and was moderately cognitively impaired, as indicated by a Brief Interview of Mental Status (BIMS) score of 10 out of 15. The resident was dependent on staff for transfers, toileting, and dressing, and was wheelchair-bound. The Nursing Home Administrator did not report the incident to the State Agency, citing that the resident did not feel abused or unsafe, and used an incorrect algorithm intended for resident-to-resident abuse to make this determination.
Failure to Monitor Resident with History of Bowel Obstruction and UTI
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for a resident with a history of small bowel obstruction and urinary tract infections. The resident, who was admitted with multiple diagnoses including paraplegia, spinal stenosis, and chronic constipation, presented with symptoms of nausea, vomiting, and abdominal pain. Despite these symptoms and the resident's medical history, the facility did not conduct thorough assessments or provide continuous monitoring, such as obtaining vital signs and observing for emesis, as required. The facility also neglected to monitor the resident's condition every shift by failing to obtain vital signs and observe the appearance of the resident's urine while suspecting a urinary tract infection and awaiting urine analysis results. Additionally, the facility did not monitor the resident's fluid intake every shift or notify the resident's medical doctor of low fluid intakes, which is crucial given the resident's condition and history. Interviews with facility staff, including the Nurse Manager, Nurse Practitioner, and Director of Nursing, revealed that the necessary monitoring and documentation were not performed. Staff acknowledged that vital signs, urine appearance, and fluid intake should have been recorded every shift, and any changes in the resident's condition should have been promptly reported to the medical doctor or nurse practitioner. The lack of adherence to these protocols contributed to the deficiency in care provided to the resident.
Failure to Timely Report Non-Consensual Sexual Touching
Penalty
Summary
The facility failed to report an incident of non-consensual sexual touching to the state agency within the required timeframe. On 4/8/24, a resident (R4) reported that another resident (R2) entered her room, touched her buttock, and pulled his pants down. Despite R4 reporting the incident to facility staff on the same day, the facility did not report the incident to the state agency until 4/10/24. The facility's policy mandates that such incidents should be reported immediately, but not later than 2 hours if the events involve abuse or result in serious bodily injury, or within 24 hours if they do not involve serious bodily injury. The delay in reporting was due to the facility's initial assessment that R4 did not view the incident as sexual assault and felt safe, which led them to believe an investigation was not necessary at that time. R2, who has dementia and is severely cognitively impaired, was placed on 15-minute checks following the incident. R4, who is cognitively intact, expressed that she did not feel scared or fearful and did not view the incident as sexual assault initially. However, on 4/10/24, R4 shared additional information with the psych NP, indicating that she felt sexually assaulted and had PTSD from past relationships. This new information prompted the facility to start an investigation and report the incident to the state agency. Interviews with facility staff, including the Social Worker (SW J), Director of Nursing (DON B), and Assistant Nursing Home Administrator (ANHA C), revealed that the facility took immediate steps to ensure R4's safety by offering to move her room and implementing 15-minute checks for R2. However, the facility did not initiate an investigation or report the incident to the state agency until they received additional information from the psych NP on 4/10/24. The facility's failure to report the incident within the required timeframe constitutes a deficiency in adhering to their abuse, neglect, and exploitation policy.
Failure to Prevent Substance Abuse and Ensure Resident Safety
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices to prevent accidents for a resident with known self-injurious behavior. The resident, who has a history of polysubstance abuse and was admitted with diagnoses including anxiety, depression, and quadriplegia, tested positive for THC and fentanyl multiple times while under the facility's care. Despite the resident's care plan indicating a need for interventions to prevent self-injurious behavior, the facility failed to implement effective measures to protect the resident from further accidents and substance abuse. On one occasion, the resident was found unresponsive in his room and tested positive for THC, fentanyl, and cocaine. An investigation revealed that the resident's brother had been on the property and provided the resident with drugs. Although the facility issued a no-trespassing order for the brother and required supervised visitations, they did not adequately inform all staff members of these measures. As a result, the resident's brother was able to visit the facility without detection, leading to further substance abuse by the resident.
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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