Wheaton Franciscan Hc - Terrace At St Francis
Inspection history, citations, penalties and survey trends for this long-term care facility in Milwaukee, Wisconsin.
- Location
- 3200 S 20th St, Milwaukee, Wisconsin 53215
- CMS Provider Number
- 525552
- Inspections on file
- 27
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Wheaton Franciscan Hc - Terrace At St Francis during CMS and state inspections, most recent first.
A resident with progressive MS and intact cognition refused a new bed when the facility implemented a building-wide bed replacement, but staff and a corporate representative proceeded to replace the bed and mattress despite her objections. After the change, the resident repeatedly reported severe back and hip pain attributed to the new bed, and documentation showed a significant increase in pain scores and frequent PRN Norco use during this period. When staff later agreed to switch her back to an older bed, an ISW and housekeeping moved numerous personal items out of her room, and housekeeping unilaterally took some of these belongings to a garbage chute room without the resident’s consent, contrary to her care plan that directed staff not to remove items without her participation. The resident became visibly upset when she discovered missing items and reported that not all of her belongings, including a bag of snacks, were returned, demonstrating a failure to respect her dignity, self-determination, and property.
A resident with a traumatic brain injury developed a full-thickness non-pressure wound on the right upper scapula that was initially assessed and treated by a wound care physician, with orders for weekly follow-up, repositioning, off-loading, and daily dressing changes. Facility policy required weekly documentation of wound appearance, measurements, treatment, and evaluation, and updating the plan of care with each intervention. However, after an assessment by the wound care physician, there was no comprehensive wound assessment documented for several weeks, and the wound was never added to the resident’s care plan, leaving no documented, person-centered interventions to promote healing. Interviews with the DON and an RN/unit manager confirmed the absence of these assessments and the missing care plan entry, while a surveyor observation confirmed the ongoing presence of the wound.
A resident with multiple comorbidities, a history of a healed stage 3 coccyx ulcer, and continuous bowel and bladder incontinence developed a new facility-acquired sacral pressure injury that was not comprehensively assessed or staged at onset, and the care plan was not revised with individualized interventions such as specific turning/repositioning and incontinence-check frequencies. Initial documentation of the wound lacked detailed assessment data, and hospice records contained no comprehensive wound assessment. When the wound physician later documented the ulcer as an unstageable full-thickness necrotic pressure injury and ordered a daily regimen including calcium alginate and collagen powder with a border dressing, the orders were not correctly transcribed to the TAR, collagen powder was omitted, and both the prior Mepilex-every-3-days treatment and the new daily treatment were signed as completed without clarification. An LPN reported performing only the less frequent border dressing, discontinuing the alginate due to resident discomfort without notifying the wound physician, and there was no evidence of consistent weekly RN wound assessments or a formal process to assign these assessments when the wound physician was absent.
Three residents experienced deficiencies in accident prevention due to staff failing to follow care plans and proper procedures. One resident suffered a femur fracture when a CNA transferred the resident alone with a sit-to-stand lift, did not use the required leg brace, and was not properly supported during transfers. Another resident, who is severely cognitively impaired, was repeatedly observed without a required floor mat at the bedside, despite care plan instructions. A third resident, also with severe cognitive impairment, was not toileted after meals as required, leading to self-transfer attempts. Staff training and documentation were incomplete or inaccurate, and care interventions were not consistently implemented.
Two residents submitted grievances regarding care issues, but the facility did not conduct thorough investigations, document corrective actions, or provide required written decisions. Grievances included concerns about catheter care, lack of bathing, delayed care, and an injury from equipment failure. Staff interviews revealed confusion about the grievance process, and required notifications and documentation were not completed.
A resident with multiple medical conditions and moderate cognitive impairment reported several instances of neglect, including incomplete showers and lack of assistance from a CNA. Despite these documented grievances, the facility did not report the allegations to the State Survey Agency or conduct a thorough investigation, as required by its own policies. Staff interviews confirmed the absence of a formal grievance process and failure to follow reporting protocols.
A resident's allegations of neglect, including incomplete showers, refusal of assistance with cleaning, and being left unattended, were documented but not thoroughly investigated or reported to the State Survey Agency as required by facility policy. Staff interviews confirmed the absence of a formal grievance process and a lack of proper investigation or reporting of these concerns.
A resident with severe cognitive and physical impairments, dependent on staff for all ADLs, was not provided with required assistance for oral care, shaving, or hair grooming. Despite a care plan and facility policy mandating daily hygiene and twice-daily oral care, observations and staff interviews confirmed these services were not performed or offered, with staff indicating that such care was often left to the resident's family.
A resident with a PICC line did not receive full dressing changes as required by professional standards and facility policy. Due to an incorrectly entered physician order, staff only changed the transparent portion of the dressing weekly, rather than the entire dressing. This error persisted until it was identified during a survey, with staff attributing the issue to the use of an incomplete order template and reliance on supervisors for order entry.
Two residents with or at risk for pressure injuries did not receive necessary assessment, treatment, or preventive interventions as required. One resident's wounds were not properly staged or assessed after hospitalizations, and prescribed treatments were missed. Another resident, identified as at risk, was repeatedly observed without required heel offloading boots, despite staff documentation stating otherwise. Staff interviews revealed inconsistent understanding of wound assessment and prevention protocols.
A resident with a suprapubic catheter did not have a StatLock device securing the catheter tubing as required by physician orders and facility policy, and staff failed to cleanse the spigot of the urinary collection bag with an alcohol pad after emptying it. These actions were observed by surveyors and confirmed through staff interviews, indicating a failure to provide appropriate catheter care.
Two CNAs did not perform required hand hygiene before, during, or after transferring a resident with a mechanical lift, nor did they clean the lift after use, in violation of facility infection control policies. The resident was dependent on staff for care and had multiple medical conditions, including cognitive impairment and a recent fracture. Despite recent staff training, the staff did not follow established protocols, and no explanation was provided for these lapses.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
A discrepancy in the appearance of a resident's liquid Morphine led to an investigation involving police notification, medication removal, and staff and resident interviews. Although the facility stated that weekly audits of narcotic medication counts would be conducted, it was unable to provide documentation that these audits occurred, resulting in a failure to demonstrate a thorough investigation of the potential misappropriation.
Three residents were not protected from accident hazards due to the facility's failure to implement and maintain required fall interventions, investigate causes of skin injuries, and update care plans with recommended therapy and preventative measures. One resident was repeatedly observed without a fall mat or bed in the lowest position, another experienced multiple skin tears without investigation or new interventions, and a third sustained a fall without therapy evaluation or care plan updates.
Two residents experienced medication administration errors when an LPN gave one resident an excessive dose of liquid Potassium Chloride via an enteral tube without required pre- and post-flushes, and administered expired insulin to another resident without proper documentation of the vial's open date. These actions resulted in a medication error rate of 18.52 percent, exceeding the acceptable threshold.
Two cognitively impaired residents with histories of behavioral issues were observed engaging in intimate and inappropriate physical contact in a public area, without documented assessment of their capacity to consent or appropriate care plan interventions. Staff witnessed and reported the incident, but the facility lacked both a policy and completed assessments for capacity to consent to sexual intimacy, and failed to update care plans or implement behavior monitoring as required.
Two residents with cognitive impairment and behavioral issues did not have accurate or updated care plans reflecting their inappropriate sexual behaviors, despite documented incidents and facility policy requiring comprehensive, person-centered care plans. Staff interviews revealed care plans were not properly updated or maintained.
Several residents with pressure injuries did not receive timely skin assessments, and wound treatments were not initiated or documented as ordered. Staff were often unaware of existing wounds, and the Registered Dietician was not consistently notified of new or worsening pressure injuries, resulting in delayed nutritional interventions. Wound physician documentation was not readily available in the medical record, and facility practices did not align with established policies for pressure ulcer prevention and care.
A resident with a suprapubic catheter and a history of UTIs did not consistently receive or have documented physician-ordered catheter care, site cleaning, and prophylactic antibiotics. Over a 20-day period, multiple treatments and medication doses were missed or not recorded, and staff care practices did not align with orders. The resident experienced several UTIs and was ultimately hospitalized for acute encephalopathy due to a UTI.
Staff did not consistently follow infection prevention protocols, including the use of transmission-based and enhanced barrier precautions, and failed to properly clean and disinfect glucometers between resident uses. PPE carts were placed outside rooms without appropriate signage, and staff were often unaware of the required precautions or how to access this information. Additionally, there was no comprehensive process for tracking or analyzing infection data, and several staff members reported not receiving training on infection control procedures.
The facility failed to ensure proper wound care and documentation for several residents, including delayed initiation of physician-ordered treatments, incomplete wound assessments, and missing wound physician documentation in the medical record. Additionally, code carts on multiple floors were not consistently checked or maintained, with missing or expired supplies and unclear staff responsibility for monitoring, resulting in a lack of readiness for emergency situations.
Medication carts on multiple units were repeatedly found unlocked and unattended, including in open areas and rooms visible from hallways, with no staff present. LPNs responsible for the carts acknowledged that they should have kept them locked when not in direct supervision, in accordance with facility policy. The DON confirmed that leaving medication carts unsecured and unattended was not acceptable.
Surveyors found that the facility did not notify physicians when medications were missed or administered late for several residents, despite facility policy requiring such notification. Observations and record reviews showed that medications were not given as ordered, and staff interviews revealed inconsistent understanding and implementation of notification procedures. High nurse workloads and lack of support contributed to delays, but there was no documentation that physicians were informed or consulted about these medication issues.
A resident requiring substantial assistance with ADLs, including bathing, received only one bath over nearly six weeks despite being care planned for twice-weekly bathing. The resident, who had multiple medical conditions, reported feeling unclean and stated that repeated requests for bathing assistance were unmet. Staff interviews revealed that routine bathing was often missed due to staffing shortages, and required documentation of refusals or missed care was not completed. The DON confirmed the lack of records and stated that residents were expected to receive bathing as care planned.
Three residents who experienced falls did not have their incidents reviewed by the IDT, and their care plans were not updated with new interventions as required by facility policy. Although immediate post-fall assessments and notifications were completed, there was no documentation of root cause analysis or care plan modifications to prevent further falls, as confirmed by the DON.
Multiple residents did not receive their prescribed medications as ordered due to pharmacy delivery delays, lack of timely medication ordering, and staff not having access to contingency medication supplies. Medications were often administered late or not at all, with some being inappropriately crushed, and documentation was inconsistent. In some cases, residents self-administered critical medications without proper assessment or physician authorization, and staff were unable to enter or follow new orders in the electronic medical record, leading to further delays and omissions in care.
Three residents experienced significant medication errors due to the facility's failure to ensure timely administration and availability of prescribed medications. One resident did not receive a critical cancer medication for multiple days, with doses marked as given despite the medication being unavailable, and self-administration occurred without proper assessment or physician authorization. Another resident had a delay in starting IV antibiotics after hospital discharge due to pharmacy and communication issues, with inconsistent documentation of administration. A third resident missed several morning doses of multiple medications because they left for scheduled appointments before receiving them, and no adjustments were made to the medication schedule.
A resident with acute osteomyelitis and an infected foot ulcer missed four vancomycin infusions due to a delay in receiving a required trough level result from the laboratory. Despite multiple follow-up attempts by the DON, the lab result was not available in a timely manner, leading to the interruption of the resident's antibiotic therapy as ordered by the physician.
The facility exhibited a 32% medication error rate, affecting two residents. A resident received a discontinued Folic Acid supplement and had medications administered late, while another received excess Fluticasone Propionate and late blood pressure medication. The facility's vague medication administration policy contributed to these errors.
Two residents in the facility did not receive adequate pain management, as observed during a survey. One resident did not receive the prescribed topical pain relief medication correctly, and there were incomplete pain assessments and evaluations of pain interventions. Another resident experienced similar issues, with a lack of documentation regarding pain assessments and medication effectiveness. The facility's policy on pain management was not followed, leading to inadequate pain relief and documentation.
The facility failed to ensure accurate medication dispensing and proper equipment labeling for two residents. A resident received incorrect dosages of Hydrocodone due to discrepancies between the MAR and narcotic count sheet, affecting pain management. Additionally, the resident's Protonix was not administered as prescribed. Another resident's glucose monitor was improperly labeled, risking potential errors. The DON could not explain the discrepancies during the survey.
The facility failed to provide adequate care and documentation for two residents. One resident did not receive timely wound care as per hospital discharge instructions, leading to severe sepsis. Another resident did not have complete neurological checks following an unwitnessed fall, as required by facility policy. These deficiencies highlight lapses in following medical orders and documentation protocols.
The facility failed to provide adequate supervision and safety measures, resulting in multiple injuries for three residents. One resident sustained unexplained bruises and fractures, another fell due to an inaccessible reacher, and a third was improperly transferred by a single CNA despite requiring a Hoyer lift. The facility did not thoroughly investigate these incidents or ensure adherence to care plans, highlighting a lack of proper supervision and preventive measures.
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development and deterioration of pressure injuries. One resident's air mattress was incorrectly set, and no care plan revisions were made following the development of pressure areas. Another resident was not repositioned as per the care plan, and treatments were not completed. A third resident had a deep tissue injury with delayed treatment and no heel boots observed during the survey.
The facility failed to maintain sanitary conditions in food service, with a Food Service Associate not wearing a beard net and dish machines not reaching required temperatures. FSAs did not use test strips to verify sanitizer concentration, and logs were incomplete, lacking managerial oversight.
The facility failed to maintain an effective infection control program, with deficiencies in the Water Management Plan, infection surveillance, and adherence to infection control practices. The WMP was outdated and lacked necessary components, while infection surveillance did not adequately track or address increased infection rates. Staff failed to wear appropriate PPE and perform hand hygiene, and a resident's urinary catheter bag was not handled hygienically.
The facility failed to complete and submit quarterly MDS assessments within the required timeframe for six residents due to EMR downtime and staff absence. The RN/MDS-G was working on completing the overdue assessments, with a target date set for the transition to new ownership. The facility's Emergency Preparedness plan lacked specific instructions for MDS completion during EMR downtime, and despite additional documentation, the issue remained unresolved.
The facility failed to ensure that a licensed pharmacist's monthly drug regimen reviews were acted upon for five residents. The reviews contained recommendations for medication adjustments, but there was no evidence of physician response or action. The MRRs were either missing, not signed, or not acted upon by the physician, leading to deficiencies in medication management.
A resident with multiple sclerosis and anxiety was not involved in her care planning, leading to an incident where her personal belongings were removed without consent. This caused her to feel violated and anxious about staff entering her room. The facility failed to update her care plan to address these concerns until after a surveyor's intervention, contributing to her reluctance to leave her room.
A resident with multiple injuries, including bruising and fractures, was not reported to the State Survey Agency by the LTC facility. Despite the facility's policy requiring prompt reporting of injuries of unknown origin, the injuries were attributed to self-infliction or equipment issues without sufficient evidence. The facility's failure to report these injuries was identified during a surveyor's investigation.
A resident with multiple medical conditions, including dementia and heart failure, sustained unexplained bruises and fractures. The facility failed to report these injuries to the state agency or conduct a thorough investigation, as required by their policy. The facility's explanations for the injuries were not supported by evidence, and documentation was insufficient, with no comprehensive investigation conducted.
A resident with dementia and heart failure, receiving hospice care, was not properly communicated about significant changes in their condition. The facility failed to notify the resident's HCPOA and primary physician about multiple incidents, including a transfer to the ER, development of a pressure ulcer, and missed pain medication doses, violating their notification policy.
The facility failed to complete timely annual MDS assessments for two residents due to a lack of access to electronic medical records (EMR) and an inadequate emergency preparedness plan. The assessments, which were due in May, were not completed until July, resulting in a delay in reviewing and updating care plans. The facility's EMR Disaster and Downtime Process did not include instructions for handling MDS assessments during downtime.
A resident with a urostomy and PICC line was observed multiple times with their catheter bag visible from the hallway, not covered in a privacy bag. Despite the resident's intact cognition, the care plan was not updated to reflect their preference regarding the visibility of the catheter bag. The facility failed to ensure the resident's dignity and privacy, as the care plan did not document the resident's wishes, leading to a deficiency noted by the surveyor.
A resident with chronic respiratory failure was found to have unlabeled oxygen tubing and a dry humidification jar, contrary to the facility's policy. The facility's procedure requires labeling and periodic checking of the humidification jar, but these steps were not followed, as observed during the survey. The unit manager and nursing home administrator acknowledged the deficiency.
A resident received Ativan 0.5 mg every eight hours as needed without a stop date or documented rationale for extending the PRN order beyond 14 days, contrary to facility policy. The resident, with multiple diagnoses including anxiety disorder, was under hospice care, and the hospice team was responsible for medication orders. However, there was no communication or documentation from the hospice team regarding the rationale for the extended use of Ativan, leading to a deficiency noted by the surveyor.
A resident with multiple medical conditions and impaired decision-making skills was not offered routine dental care since admission, despite having poor oral health and expressing a desire for dental services. The facility's policy requires dental services to be available and documented, but there was no care plan or record of the resident being on the dental list. Staff interviews revealed a lack of communication and documentation, and the issue was only addressed after being highlighted by a surveyor.
A resident with Parkinson's Disease and dysphagia did not receive necessary assistive eating equipment at a facility. Despite a nutrition risk assessment indicating the need for special utensils and cups, these were not provided, leading to the resident's inability to eat independently. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, resulting in meals being left untouched.
The facility failed to coordinate hospice services for two residents, resulting in missing hospice visit notes and incomplete recertification of terminal illness. Staff were unaware of hospice schedules and lacked a designated liaison for communication. This led to care issues not being addressed timely, violating the facility's obligations under the hospice agreement.
Failure to Honor Resident’s Refusal of Bed Change and Mishandling of Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s rights to dignity, self-determination, and respect for her personal belongings during a facility-wide bed replacement. The resident, who has progressive multiple sclerosis, hypertension, and glaucoma, had a BIMS score of 15 indicating she was cognitively intact. When approached about changing her bed as part of a project to replace older beds, she explicitly refused, but her bed was nonetheless changed on 11/25/25 after facility staff and a corporate representative insisted that all beds had to be replaced. The Chaplain and DON were present when the bed and mattress were changed, and the Chaplain confirmed that the resident did not want her bed changed but it was done because beds throughout the facility were being replaced. Following the bed change, the resident repeatedly complained to multiple staff that the new bed was causing significant back and hip pain, stating she could feel the bars in her back and could not stand up. She reported these concerns to nurses, the Chaplain, and the NP. Progress notes document her complaints of increased pain in the right hip and lumbar area and a request for an x-ray, which was obtained and reviewed. Review of the MARs showed that prior to the new bed, her pain scores were consistently 0 with very limited PRN Norco use, but during the period she had the new bed, there was a marked increase in documented pain scores and frequent administration of PRN Norco 5/325 mg for breakthrough pain. The social worker later documented that the resident reported the new bed was causing back pain and that she preferred the older model and wanted it switched back. When the facility eventually agreed to switch the resident back to an older bed and mattress on 12/18/25, the process of moving her belongings was not handled in accordance with her care plan and rights. The resident had a care plan problem related to hoarding and a history of displacement, with an explicit approach to avoid removing items from her room without her participation. Despite this, the interim social worker and housekeeping staff moved multiple personal items from the bed, under and around the bed, and placed them in the hallway, and housekeeping then took some of these belongings to the garbage chute room as part of an effort to “clean” the room, without asking the resident which items could be discarded. The resident, who typically did not leave her room, came into the hallway visibly upset when she realized items were missing. Housekeeping acknowledged placing the resident’s belongings in the garbage chute room and then retrieving them after the resident became upset, but the resident reported that not all items were returned, including a bag with snacks she valued. The facility’s own resident rights policy states that residents are entitled to exercise their personal rights to the fullest extent possible and to always be treated with respect, kindness, and dignity, which was not followed in this situation.
Failure to Complete Weekly Wound Assessments and Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide comprehensive weekly assessment and care planning for a resident’s non-pressure wound in accordance with facility policy and physician orders. The facility’s skin policy dated 11/2022 requires licensed nursing staff to document weekly integumentary findings, including wound appearance, measurements, treatments applied, and evaluation, and to update the plan of care with each intervention. The resident, admitted with a traumatic brain injury and having a guardian, was seen by a wound care physician on 12/4/25 and identified as having a full-thickness non-pressure wound to the right upper scapula measuring 6 cm by 6 cm by 0.1 cm with light serous drainage and 10% necrotic tissue. On 12/11/25, the wound care physician documented that the wound measured 6 cm by 3 cm by 0.1 cm with light serous drainage and 20% slough, which was debrided, and recommended continued treatment with a gauze island border dressing, repositioning per facility protocol, and off-loading of the wound, with weekly follow-up. A subsequent wound care visit on 12/18/25 was rescheduled due to the resident’s refusal of wound evaluation. Despite these findings and orders, the resident’s medical record contained no comprehensive wound assessment after 12/11/25 through 1/6/25, even though the DON stated that the wound care doctor comes weekly and that either the RN manager or floor nurse would conduct wound rounds and assessments. The resident’s plan of care did not identify the non-pressure wound, and therefore contained no documented, person-centered interventions to promote healing or to evaluate whether interventions or treatments needed adjustment. Interviews with the DON and RN/unit manager confirmed that they could not produce any comprehensive wound assessments after 12/11/25 and that the wound had not been added to the care plan, with the RN/unit manager stating that the MDS nurse completes care plans but not knowing why the wound was not included. During an observation on 1/5/26, the surveyor noted two wound areas on the resident’s right upper scapula consistent with the 12/11/25 assessment, further confirming the ongoing presence of the wound without corresponding weekly assessments or care plan documentation.
Failure to Provide Comprehensive Pressure Injury Prevention, Assessment, and Treatment
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury prevention and treatment consistent with professional standards of practice for one hospice resident with multiple comorbidities, including primary progressive MS, chronic kidney disease, osteoporosis, severe protein-calorie malnutrition, and cirrhosis. The resident was always incontinent of bowel and bladder and had a prior history of a stage 3 coccyx pressure injury that had healed earlier in the year. The care plan identified the resident as at risk for pressure ulcers and included general interventions such as encouraging peri hygiene with barrier cream after incontinence, observing skin for redness and breakdown, use of a low air loss mattress, heel floating, use of a pressure-relieving cushion, turning and repositioning during rounding, and use of a lift sheet. However, the care plan did not specify person-centered details such as the frequency of turning and repositioning or how often the resident should be checked and changed for incontinence, despite documentation that the resident was always incontinent. A new facility-acquired pressure injury to the sacrum/coccyx was identified on 12/11/25, documented as a full-thickness wound measuring 1.0 x 0.5 cm. The skin assessment summary did not include a comprehensive assessment: depth was not documented, wound bed color was marked as inapplicable, and the stage was entered as “Further assessment required.” Treatment ordered at that time was to cleanse with normal saline and apply zinc covered with a foam dressing, and a hospice nurse note indicated a new order for cleansing with normal saline, barrier cream to non-open areas, and Mepilex dressing. The December TAR showed the Mepilex treatment every three days was signed as completed through the end of the month. There was no comprehensive hospice documentation of the wound, and the resident’s care plan was not revised to reflect the new pressure injury or to add new, individualized interventions. An RN later stated that when new wounds are found, staff “just measure it” and “don’t stage wounds,” and there was no documentation of wound characteristics such as appearance or exudate at the time of discovery. On 12/18/25, the wound physician assessed the sacral wound and documented it as an unstageable full-thickness pressure injury due to necrosis, measuring 7 cm x 10 cm with moderate serous exudate and 20% thick adherent devitalized necrotic tissue. The physician ordered a dressing regimen including daily calcium alginate and collagen powder with a gauze island border dressing. The facility did not correctly transcribe these orders to the TAR: collagen powder was omitted, and both the original Mepilex every-three-days treatment and the new daily alginate regimen were signed out as completed concurrently. Staff did not clarify with the wound physician which treatment should be discontinued. An LPN later reported she had only been performing the three-times-weekly border dressing, had not been using the calcium alginate because the resident complained it burned, and had not contacted the wound physician; there was no documentation that any physician was notified that the ordered treatment was not being followed. Weekly comprehensive wound assessments and measurements were not consistently completed by an RN in the absence of the wound physician; the next documented assessment with measurements after 12/18/25 did not occur until 12/29/25, was entered by an LPN, and repeated the physician’s prior measurements and description. The DON acknowledged that nurses were only verbally told to assess wounds when the wound doctor would not be present and that there was no formal assignment or sign-out process for these weekly assessments.
Failure to Prevent Accidents Due to Inadequate Supervision and Noncompliance with Care Plans
Penalty
Summary
The facility failed to ensure that three out of five residents received adequate supervision and assistive devices to prevent accidents, as evidenced by multiple observations, interviews, and record reviews. One resident sustained a left femur fracture when a CNA transferred the resident alone using a sit-to-stand lift, despite care instructions requiring two staff for transfers. The lift lost power during the transfer, and the resident's leg gave out, resulting in a fracture. Following the incident, the resident was observed multiple times without the required leg brace, and staff were seen operating the mechanical lift incorrectly, including not supporting the resident's injured leg and not following proper lift procedures. Additionally, a physician-ordered follow-up x-ray was not obtained, and documentation indicated staff were marking the x-ray as completed when it was not. Staff training on lift use was incomplete, and agency staff did not receive competency evaluations. Another resident, who is severely cognitively impaired and dependent for care, was observed repeatedly without a floor mat at the bedside, contrary to the care plan and CNA worksheet instructions. The floor mat, intended as a fall prevention measure, was found folded and not in use during multiple observations across different shifts. Staff did not place the mat at the bedside during or after care, and when questioned, a CNA stated she had not moved the mat. The issue was brought to the attention of nursing management, but the mat remained unused at the resident's bedside throughout the survey period. A third resident, also severely cognitively impaired and at risk for falls, was not toileted after meals as required by the fall prevention care plan. The resident was observed self-transferring to the toilet without staff assistance, despite being care planned for substantial assistance with transfers and toileting. Staff did not follow the intervention to toilet the resident after meals, and the resident was found on the toilet by a CNA, who then instructed the resident not to self-transfer in the future. The failure to follow the toileting intervention was confirmed by staff interviews and direct observation.
Failure to Provide Required Written Grievance Decisions and Investigations
Penalty
Summary
The facility failed to ensure that all written grievance decisions included the required elements such as steps taken to investigate the grievance, a summary of pertinent findings or conclusions, a statement as to whether the grievance was confirmed or not, any corrective action taken, and the date the written decision was issued. This deficiency was identified for two residents who had submitted grievances regarding their care and services. In both cases, the facility did not conduct thorough investigations, did not document corrective actions, and did not provide written decisions to the residents or their representatives. One resident, who had multiple complex medical diagnoses including hypertension, heart failure, and chronic pain, had a grievance submitted by her daughter regarding inadequate catheter care and lack of bathing. The grievance was acknowledged by the administrator through a phone call, but there was no documentation of an investigation, staff interviews, or corrective actions taken. The only notification provided was verbal, and no written resolution was issued as required by facility policy. Another resident, with diagnoses including heart disease, atrial fibrillation, anemia, hypothyroidism, depression, and dementia, had multiple grievances submitted by herself and her daughter. These grievances included concerns about delayed care, lack of regular care conferences, and an incident resulting in a femur fracture. The facility's documentation did not show that thorough investigations were conducted or that written notifications of resolutions were provided. Interviews with staff revealed confusion and lack of clarity regarding responsibility for the grievance process, and the required follow-up actions and documentation were not completed.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to ensure that allegations of neglect involving a resident were immediately reported to the Administrator and/or Grievance Officer and submitted to the State Survey Agency as required by policy. Record review and interviews revealed that a grievance dated 8/27/25 documented multiple concerns, including incomplete showers, refusal by a CNA to assist a resident with cleaning up spilled food, and another resident being left unattended when requesting assistance to prepare for therapy. Despite these documented allegations, the facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report or a Misconduct Incident Report to the State Survey Agency. The facility's Abuse Prevention and Abuse Investigation and Reporting policies require that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the Administrator or designee and to the State Agency within specified time frames. The policies also require that findings of investigations be reported in writing within five working days. However, interviews with facility staff, including the Social Worker and Nursing Home Administrator, confirmed that there was no formal grievance process in place and that the allegations of neglect were not reported or thoroughly investigated as required. The resident involved had a history of significant medical conditions, including atherosclerotic heart disease, paroxysmal atrial fibrillation, iron deficiency anemia, hypothyroidism, major depressive disorder, and dementia. The resident was moderately cognitively impaired but alert and oriented at the time of the survey. The surveyor found that the facility's failure to report and investigate the allegations of neglect constituted a deficiency in compliance with regulatory requirements.
Failure to Investigate and Report Allegations of Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of neglect involving a resident, as required by its own policies and federal and state regulations. The surveyor reviewed a grievance dated 8/27/25, which documented several concerns: showers not being completed with one CNA documenting multiple refusals while other staff were able to accomplish the task, a resident reporting that a CNA refused to help clean up spilled food, and another resident stating that a CNA left her unattended when she wanted to get up for therapy. Additionally, a grievance from 8/8/25 noted that a resident was late to lunch because a CNA paused care to use the phone. These grievances were entered into the facility's log, and at least one resulted in a documented counseling session for the CNA involved. Despite these documented concerns, the facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report or a Misconduct Incident Report to the State Survey Agency. The facility's policies require immediate reporting and thorough investigation of all allegations of abuse, neglect, or mistreatment, including interviews with the resident, witnesses, and staff, as well as submission of findings to the appropriate agencies within specified timeframes. However, the surveyor found that these steps were not followed, and the allegations were not reported as required. Interviews with facility staff revealed that the social worker was only involved in entering grievances into a spreadsheet and not in the investigation process. The Nursing Home Administrator confirmed that there was no formal grievance process in place at the time and acknowledged that the allegations of neglect were not thoroughly investigated or reported to the State Survey Agency. No additional information was provided to explain the lack of investigation and reporting.
Failure to Provide Required ADL Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis and spastic paraplegia, who was assessed as being dependent on staff for all activities of daily living (ADLs) including oral hygiene, grooming, and shaving, did not receive the necessary assistance for these tasks. The resident's care plan specified total assistance with grooming, oral care twice daily, and shaving every other day. Despite these documented needs and facility policy requiring daily personal hygiene and twice-daily oral care, observations and interviews revealed that these services were not provided as required. Surveyor observations over two consecutive days showed that the resident was not offered or provided with oral care, shaving, or hair brushing/combing during morning care routines. The resident was repeatedly observed with unshaven facial hair and disheveled hair, and confirmed that oral care was not performed before breakfast. Staff interviews further indicated a lack of awareness or adherence to the care plan, with a CNA stating that oral care was performed only every other day and expressing uncertainty about the availability of oral swabs for residents unable to use a toothbrush. The CNA also reported that shaving and hair brushing were typically performed by the resident's wife rather than facility staff. The facility's own policy and the resident's care plan both required staff to provide and document daily personal hygiene and oral care, as well as regular shaving and grooming. However, direct observations and staff interviews confirmed that these essential care activities were not consistently performed or offered, resulting in the resident not receiving the necessary services to maintain good grooming and hygiene as required.
Failure to Provide Complete PICC Line Dressing Changes per Standards
Penalty
Summary
A deficiency occurred when a resident with a right upper extremity peripherally inserted central catheter (PICC) did not receive dressing changes in accordance with professional standards of practice. Upon the resident's readmission, the physician's order for PICC line care was incorrectly entered, specifying only the transparent portion of the dressing to be changed weekly, rather than the entire dressing as required. Facility staff, including LPNs and CNAs, followed this order and only changed the transparent cover, not the full dressing, for several weeks. The facility's own policy and standard practice require the entire dressing to be changed every 5-7 days or sooner if compromised. The error in the order entry was attributed to the use of a pre-set order template in the facility's electronic library, which only referenced the transparent dressing. Staff interviews revealed that the process for entering orders involved supervisors and higher-level staff, and the LPNs relied on these orders for care delivery. The deficiency was identified during a surveyor's observation and interviews, which confirmed that the resident's entire PICC line dressing had not been changed weekly since readmission, contrary to both facility policy and accepted standards of care.
Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries and to promote healing for two residents, both with significant risk factors and existing pressure injuries. For one resident with multiple sclerosis and spastic paraplegia, there were multiple instances of inaccurate or incomplete wound assessments, including incorrect staging of pressure injuries and lack of detailed wound bed descriptions. After hospitalizations, assessments were delayed, and some areas previously identified as pressure injuries were not reassessed by a registered nurse or wound specialist until several days after readmission. Additionally, prescribed treatments were not consistently administered, as observed when a nurse failed to apply the ordered treatment to a pressure injury on the resident's right lateral foot. During morning care, staff did not apply skin protectant as ordered, and the nurse manager confirmed that this should have been done. For the second resident, who was at risk for pressure injury development due to immobility, incontinence, and recent fracture, staff failed to implement required preventive measures. The resident's care plan and CNA worksheet specified the use of heel suspension boots and offloading of heels while in bed. However, repeated observations by the surveyor over several days found the resident in bed without the boots on and heels not offloaded. Despite this, nursing staff documented in the treatment administration record that the boots were in place and heels were offloaded, which was inconsistent with direct observations and staff interviews. The LPN confirmed that if the resident refused the boots, this should have been documented, but there was no such documentation. The facility's policy on pressure injury assessment and treatment did not address the required assessment process upon admission or readmission, nor did it specify the necessary components of a pressure injury assessment. Interviews with nursing staff revealed inconsistent understanding and application of wound assessment standards, including staging and wound bed description. These failures resulted in inadequate monitoring, documentation, and implementation of pressure injury prevention and treatment protocols for residents at risk or with existing wounds.
Failure to Provide Proper Catheter Care and Adhere to Physician Orders
Penalty
Summary
A deficiency was identified when a resident with multiple sclerosis, spastic paraplegia, and neuromuscular dysfunction of the bladder, who had a suprapubic catheter, did not receive care in accordance with physician orders and facility policy. The resident's care plan and physician orders required the use of a StatLock device to secure the catheter, to be changed weekly and as needed. During surveyor observations, the resident was found without a StatLock securing the catheter tubing, and staff did not notice its absence until it was pointed out by the surveyor. Additionally, during the process of emptying the resident's urinary collection bag, a CNA failed to cleanse the end of the spigot with an alcohol pad before returning it to the holder, contrary to facility policy and the procedure described by the Director of Nursing. The CNA emptied the urine into a graduate and then into the toilet, but did not clean the spigot, which was confirmed by both observation and staff interview. These actions did not meet the standards outlined in the facility's urinary catheter care policy.
Failure to Follow Hand Hygiene and Equipment Cleaning Protocols During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to the facility's infection prevention and control policies during the transfer of a resident with multiple medical conditions, including dementia, heart disease, and a recent femur fracture. During an observed transfer using a mechanical lift, two CNAs placed gloves on without performing hand hygiene beforehand, did not perform hand hygiene after removing gloves, and failed to perform hand hygiene at other required points during resident care. Additionally, after the transfer, the mechanical lift was not wiped down as required by facility policy. Both CNAs exited the resident's room without performing hand hygiene, and one CNA handled resident care items and assisted the resident without hand hygiene or glove use. The resident involved was moderately cognitively impaired, dependent on staff for transfers and personal care, and at risk for pressure injuries. The facility's policies clearly require hand hygiene before and after resident contact, after glove removal, and after use of equipment such as mechanical lifts. Despite recent staff training on hand hygiene, the observed staff actions did not comply with these protocols, and no explanation was provided by the facility for the failure to follow infection control procedures.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Document Investigation of Narcotic Discrepancy
Penalty
Summary
The facility failed to ensure that an alleged violation involving possible misappropriation of a resident's narcotic medication was thoroughly investigated. A discrepancy was identified in the appearance of a resident's liquid Morphine, which appeared lighter in color than usual. The facility reported the incident to the State Agency, notified the police, removed the medication from the cart, and conducted interviews and pain assessments. The facility's investigation concluded that there was no substantiated evidence of misuse and suggested the color change could be due to the medication's age and infrequent use. However, the facility committed to conducting weekly audits of narcotic medication counts for six weeks to enhance monitoring, including documentation of the color and consistency of all liquid medications. When the surveyor requested documentation of these audits, the facility was unable to provide them. Despite multiple requests and attempts to locate the records, the facility could not produce evidence that the weekly audits were performed, leaving it unclear whether a thorough investigation into the potential misappropriation was completed.
Failure to Prevent Accidents and Implement Fall Interventions
Penalty
Summary
Three residents were not adequately protected from accident hazards, and the facility failed to provide sufficient supervision and interventions to prevent accidents. One resident with vascular dementia, anemia, and depression, who was assessed as being at risk for falls and required extensive assistance with activities of daily living, was observed multiple times without required fall interventions in place. Specifically, the resident's bed was not maintained in the lowest position, and a fall mat was not present at the bedside, despite these being recommended and documented interventions in the care plan following a previous unwitnessed fall. Staff interviews confirmed a lack of awareness and implementation of these interventions. Another resident with chronic atrial fibrillation and on blood thinning medication experienced multiple skin injuries, including skin tears and bruising, during care activities such as repositioning and transfers. There was no documentation of investigations into the causes of these injuries or implementation of new interventions to prevent further incidents. Interviews with nursing staff and review of records revealed that no root cause analysis or preventative measures were documented or put in place following these events. A third resident with dementia, weakness, and a history of repeated falls sustained an unwitnessed fall resulting in a large bruise to the forehead and face. Although a root cause analysis recommended therapy evaluations and adjustments to the toileting schedule, the care plan was not updated to reflect these interventions, and no therapy evaluation was conducted after the fall. Staff interviews confirmed that therapy services were not initiated as recommended, and the care plan lacked documentation of revisions or implementation dates for new interventions.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as evidenced by an observed error rate of 18.52 percent during the survey. Two residents were directly affected by medication administration errors. One resident was administered 15 milliliters of liquid Potassium Chloride via an enteral feeding tube, despite the physician's order specifying only 3.75 milliliters. Additionally, the enteral tube was not flushed with water prior to or immediately after medication administration, contrary to facility policy, with the post-administration flush occurring approximately one hour later. The resident was receiving tube feeding at the time, which was stopped for medication administration, but the required flushing steps were not followed. Another resident was given insulin (Humalog/Lispro) that was past its discard date, as indicated on the packaging. The insulin vial also lacked an open date, which is required by facility policy to ensure proper tracking and timely disposal. The LPN responsible for administering these medications did not adhere to established protocols for medication administration, including checking expiration dates and following procedures for enteral tube medication delivery. These actions were confirmed through direct observation, staff interviews, and review of physician orders and facility policies.
Failure to Assess Capacity and Protect Residents from Potential Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from potential abuse when they were observed engaging in physical intimacy, including holding hands, kissing, and inappropriate touching, without documented assessment of their capacity to consent. Both residents had significant cognitive impairments, as evidenced by low or incomplete BIMS scores, and both had histories of behavioral issues, including sexual inappropriateness and wandering. Despite these factors, the facility did not complete or have a policy for assessing capacity to consent to sexual intimacy for either resident. Staff members observed the two residents engaging in intimate behaviors in a public area, with multiple staff confirming the incident and reporting it to supervisory staff. The care plans for both residents did not address sexual inappropriateness or include behavior monitoring, despite documented histories of such behaviors. The facility's abuse prevention policy required investigation of sexual activity involving residents with cognitive impairment, but this was not followed as required assessments were not completed. Interviews with staff revealed that the incident was witnessed by several employees, who noted the residents' prior behavioral histories and reported the event to the appropriate personnel. However, there was a lack of timely intervention and documentation regarding the residents' ability to consent, and the care plans were not updated to reflect the risk or address the behaviors observed. The facility also lacked a specific policy on assessing capacity to consent for sexual intimacy, contributing to the failure to protect the residents from potential abuse.
Failure to Maintain Accurate Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to ensure that two residents had accurate and up-to-date care plans, as required by policy. One resident with a history of sexually inappropriate touching of other residents was observed engaging in physical contact with another resident, but his care plan was not updated to reflect inappropriate sexual behaviors. The care plan for this resident previously included impaired behavior related to touching other residents, but this was marked as resolved and not revised to address ongoing or new concerns. The resident's Minimum Data Set (MDS) also did not indicate behaviors directed toward other residents, despite documented incidents. Another resident, who had dementia with behavioral disturbances and daily wandering behaviors, did not have any care plan interventions addressing sexual inappropriateness, even though she was involved in the observed incident. Staff interviews confirmed that the care plans were not appropriately updated and that there was uncertainty regarding the resolution and documentation of behavioral issues. The facility's policy required comprehensive, person-centered care plans to be developed and revised based on assessment findings, but this process was not followed for these residents.
Failure to Provide Timely and Consistent Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for residents with existing wounds. Multiple residents were affected by lapses in timely skin assessments, initiation and documentation of wound treatments, and communication among staff and with the Registered Dietician (RD). For example, one resident was readmitted to the facility with pressure injuries, but skin assessments were not completed in a timely manner, treatments were not initiated or completed as ordered, and weekly comprehensive wound assessments were not documented. The facility staff were unaware of a pressure injury observed by the surveyor, and documentation did not match the wound physician's findings. The wound physician's documentation was not readily available in the resident's medical record, further hindering appropriate care. Another resident developed Stage 2 pressure injuries to the buttocks, but these were not comprehensively assessed, and treatment orders were not implemented as required. Treatments were inconsistently signed out as completed, and the RD was not informed of the new or existing wounds, resulting in delayed nutritional assessments and interventions. The surveyor observed additional pressure injuries that staff were unaware of, and the wound physician's documentation was not present in the medical record. The resident reported ongoing issues with skin integrity that were not being regularly evaluated by nursing staff. A third resident developed a Stage 3 pressure injury and an unstageable pressure injury, but treatment was not started until several days after identification. Treatments were not consistently documented as completed, and the RD was not notified of the wounds. The facility's own policies required timely skin assessments, initiation of protective dressings, notification of the healthcare provider and RD, and comprehensive documentation, but these steps were not followed. The surveyor's findings were based on direct observation, interviews with staff and residents, and review of medical records, all of which demonstrated a pattern of failure to provide appropriate pressure ulcer care and prevention.
Failure to Provide and Document Ordered Catheter Care and UTI Prevention
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not consistently receive physician-ordered catheter care and related treatments. The resident, who has multiple sclerosis, neuromuscular dysfunction of the bladder, paraplegia, and a history of urinary tract infections (UTIs), had several orders in place for catheter irrigation, site care, monitoring for infection, and prophylactic antibiotics. Surveyors found that over a 20-day period, there were multiple instances where these treatments and medications were not documented as completed, including missed catheter irrigations, site cleanings, and doses of prescribed antibiotics. The facility's own catheter care policy requires documentation of care provided, observation for complications, and prompt reporting of infection signs. However, the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed numerous dates where required care was not recorded. Interviews with staff revealed inconsistencies in the care provided, with a CNA describing a cleaning process that did not align with the physician's orders. The Director of Nursing acknowledged the resident's frequent UTIs but did not provide an explanation for the missed documentation or treatments. During the review period, the resident experienced multiple UTIs and was prescribed several courses of antibiotics. Ultimately, the resident was transferred to the hospital due to acute encephalopathy resulting from a UTI. The surveyor also noted a lack of ongoing urology involvement and follow-up, despite the resident's complex medical needs and repeated infections.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to consistently implement and follow infection prevention and control procedures, specifically regarding transmission-based precautions (TBP), Enhanced Barrier Precautions (EBP), and the cleaning and sanitizing of glucometers. Observations revealed that personal protective equipment (PPE) carts were placed outside several residents' rooms without appropriate signage indicating the type of precautions in place. Multiple staff members, including RNs, LPNs, CNAs, and other personnel, were unaware of the reasons for the precautions or the correct procedures to follow. The Director of Nursing (DON) and Infection Preventionist (IP) confirmed that signage should have been present and that staff should have been informed of the required precautions, but acknowledged that the electronic medical record (EMR) system was difficult to navigate and that staff were not always adequately informed during shift reports. The facility also failed to ensure proper infection prevention procedures related to the cleaning and sanitizing of glucometers. Multiple instances were observed where LPNs used glucometers on several residents without cleaning or disinfecting the devices between uses, and without placing a clean barrier between the glucometer and resident surfaces. Some staff were unaware of where to find appropriate cleaning agents, and others used disinfecting wipes incorrectly, not adhering to the required contact time or allowing the device to air dry. Several staff members reported not receiving any training on the facility's infection control policies or procedures, and agency staff in particular noted a lack of orientation or instruction regarding these protocols. Additionally, the facility did not maintain a comprehensive process for tracking, trending, or analyzing infection data as required by its own policies. Review of the infection control documentation revealed no evidence of infection tracking or data analysis for the period reviewed. The DON and IP both confirmed the absence of a comprehensive infection surveillance and analysis process, despite expectations that such a system should be in place.
Deficient Wound Care and Emergency Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate treatment and care for residents with non-pressure wounds in accordance with professional standards and physician orders. For three residents reviewed, there were significant lapses in wound assessment, documentation, and timely initiation of ordered treatments. In one case, a resident developed a non-pressure wound to the lower mid spine, but a comprehensive assessment was not completed, and no wound measurements or descriptors were documented. The wound physician's treatment order was not initiated until seven days after it was given, and subsequent wound documentation was inconsistent and incomplete. Additionally, wound physician and dermatology documentation were not available in the resident's medical record, and the dietician was not notified of the wound, leading to gaps in nutritional intervention. Another resident developed a rash to the right leg, which was not comprehensively assessed, and the wound physician's treatment order was also delayed by seven days. Documentation of wound assessments was inconsistent, and the wound physician's notes were not present in the medical record. The resident reported ongoing symptoms, such as itching and redness, and was not consistently receiving ordered treatments or interventions. A third resident was admitted with multiple wounds, but no admission skin assessment was completed until five days after admission. Wound descriptions were lacking, and treatments were not consistently documented as administered. Wound physician documentation was also missing from the medical record. The facility also failed to maintain and monitor emergency medical equipment, specifically code carts, in accordance with professional standards. Observations revealed that code carts on multiple floors were not consistently checked or documented as maintained, with missing inventory checklists, expired or missing supplies, and unclear staff responsibility for monitoring the carts. In some cases, essential equipment such as oxygen tanks was missing or empty, and documentation of code cart checks was incomplete or absent. Staff interviews confirmed a lack of clarity regarding who was responsible for code cart maintenance, and there was no evidence of a systematic process to ensure code carts were fully supplied and ready for use.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on the first, second, and third floors were left unlocked and unattended on multiple occasions. On the third floor, a medication cart was found unlocked and unattended at the nurses station with no nursing staff present. The responsible LPN confirmed he had left the cart unlocked while administering medication elsewhere and acknowledged it should have been locked. On the first floor, a medication cart was found unlocked and unattended in the charting room, with the room door open and no staff present. Similarly, on the second floor, a medication cart was observed unlocked and unattended, and the responsible LPN stated she thought she had locked it but had left to do charting in the nursing office. Additionally, the medication room on the first floor was found with its door fully open, and an unlocked, unattended medication cart was visible and accessible from the hallway. No staff were present in the medication room or at the nurses' station nearby. When the responsible LPN returned, she confirmed the cart should not have been left unlocked and unattended, as it could be accessed by residents or others. The Director of Nursing also stated that leaving medication carts unlocked and unattended was not acceptable. Facility policy requires medication carts to be kept closed and locked when out of sight of the medication nurse or aide, and no medications are to be kept on top of the cart.
Failure to Notify Physician of Missed or Late Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to notify residents' physicians when medications were not administered as ordered for seven residents. The facility's policy required documentation and physician notification for withheld, refused, or late medications, but did not address situations where medications were unavailable. In multiple cases, residents missed scheduled doses due to being out of the facility, medication unavailability, or late administration, and there was no evidence in the medical records that physicians were notified of these missed or late doses. For example, one resident with multiple complex diagnoses missed several doses of critical medications, including blood pressure and antiviral drugs, without physician notification. Direct observation and record review revealed that medications were administered outside the prescribed time frames, sometimes several hours late, and documentation of physician notification was consistently lacking. Interviews with nursing staff and the DON confirmed that the expectation was to notify the physician when medications were not administered as ordered, but this was not consistently done. In some cases, staff were unclear about the policy or stated there was no expectation to notify the physician, despite the facility's policy and the DON's stated expectations. The survey also documented workflow and staffing challenges, with nurses reporting high workloads and insufficient support, which contributed to delays in medication administration. Despite these challenges, there was no documentation that physicians were consulted regarding late or missed medications, and no evidence that the facility's policy was followed in these instances. The lack of physician notification placed residents at risk for unmet treatment needs, as the physician was not given the opportunity to address or revise treatment plans in response to missed or late medication doses.
Failure to Provide Routine Bathing Services Due to Staffing and Documentation Lapses
Penalty
Summary
The facility failed to provide routine bathing services to one resident who required substantial to maximum assistance with activities of daily living, including bathing. The resident, who was admitted with diagnoses of cellulitis of the right lower limb, morbid obesity, and chronic kidney disease, was care planned to receive a bed bath or shower twice weekly. Review of the resident's records showed that only one bath was documented during a period of nearly six weeks, with no documentation of refusals or reasons for missed baths. The facility's own procedures required documentation of bathing, refusals, and notification of supervisors if a resident declined care, but these steps were not followed. Interviews with the resident confirmed that she had only been bathed once since admission and had repeatedly requested assistance, but staff did not return to provide care. Multiple CNAs interviewed acknowledged that residents were supposed to be bathed twice weekly but cited staffing shortages as a barrier to completing all assigned baths. The Director of Nursing confirmed the lack of documentation for additional baths and stated that residents were expected to be assisted with bathing according to their care plans.
Failure to Conduct Root Cause Analysis and Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to ensure that a root cause analysis was conducted and care plans were updated following falls experienced by three residents. According to facility policy, all accidents and incidents involving residents are to be investigated, discussed by the interdisciplinary team (IDT) at the next scheduled meeting, and care plans should be reviewed and updated with individualized interventions after each fall. However, documentation revealed that after each resident's fall, there was no evidence of IDT review, root cause analysis, or updates to the residents' care plans to address the incidents. One resident with chronic kidney disease and type 2 diabetes, who was severely cognitively impaired, experienced a fall after slipping in the bathroom. Although immediate post-fall assessments and notifications were completed, there was no documentation of IDT review or care plan updates. Another resident with heart failure and chronic pulmonary embolism, also severely cognitively impaired, had an unwitnessed fall while coming from the bathroom. Similarly, post-fall assessments were performed, but no additional interventions were added to the care plan, nor was there evidence of IDT discussion. A third resident, cognitively intact with persistent atrial fibrillation and type 2 diabetes, fell out of bed, sustained a head wound, and was sent to the emergency department. Again, while immediate clinical responses were documented, there was no indication of subsequent IDT review or care plan modification. During an interview, the DON confirmed that the IDT had not addressed any of the referenced falls and that the residents' care plans had not been updated with new interventions to prevent further falls. This lack of follow-through on facility policy and federal requirements created the potential for continued falls among these residents.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to maintain adequate pharmaceutical services by not ensuring that medications were available and administered as ordered for multiple residents. Several residents did not receive critical medications, such as antibiotics, anticoagulants, and pain medications, due to issues including delayed pharmacy delivery, lack of timely medication ordering, and staff not having access to the contingency medication machine. In some cases, medications were not administered because they were not available in the facility, and staff failed to notify physicians or document the reasons for missed doses. For example, one resident did not receive vancomycin and ertapenem as ordered due to delays in obtaining necessary lab results and pharmacy delivery, while another resident missed doses of glaucoma eye drops because the medications were not on hand. Medication administration observations revealed a high error rate, with medications being given significantly outside the prescribed time windows and some medications being documented as administered when they were not actually given. Additionally, medications that should not have been crushed, such as enteric-coated and extended-release tablets, were crushed and administered inappropriately. Staff interviews indicated that agency nurses often lacked access to the automated medication contingency machine, further contributing to missed doses. There were also instances where staff did not know how to enter new physician orders into the electronic medical record, resulting in delays or omissions in care. In one case, a resident with cancer did not receive their prescribed Imatinib because the medication was delivered to their home instead of the facility, and the facility did not have a process in place to ensure the medication was available for administration by licensed staff. The resident ended up self-administering the medication brought from home, without proper assessment or documentation that they were capable of self-administration. Another resident experienced a delay in starting intravenous antibiotics after hospital readmission due to missing pharmacy orders and lack of timely follow-up by staff. These failures were confirmed through interviews with nursing staff, the DON, and the pharmacist, as well as review of medical records and facility policies.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, as evidenced by the omission or delay of necessary ordered medications. One resident with a diagnosis of myeloid leukemia did not receive the prescribed Imatinib 400mg tablet daily for a period of 14 administrations, due to the medication being delivered to the resident's home instead of the facility and subsequent issues with insurance coverage and pharmacy supply. Despite the resident's son bringing the medication from home and the resident self-administering, there was no documentation that the resident was assessed or authorized to self-administer this medication, nor was there evidence that the physician was aware of this arrangement. Additionally, some doses were incorrectly documented as administered when the medication was not available in the facility. Another resident, who returned from the hospital with an order for IV ertapenem to treat a urinary tract infection with acute encephalopathy, experienced a delay in receiving the antibiotic. The medication was not available for two days after the resident's return, with documentation discrepancies regarding the actual start date of administration. The delay was attributed to pharmacy issues, missing paperwork, and lack of timely communication between the facility, pharmacy, and hospital. The resident's medical record reflected inconsistent information about when the antibiotic therapy began, and the facility did not ensure the medication was available as ordered. A third resident with multiple chronic conditions, including acute and chronic respiratory failure and multiple myeloma, missed several scheduled morning doses of multiple medications due to leaving the facility for regular chemotherapy appointments before the medications were administered. The medications were not given at a different time, and there was no evidence that the physician was contacted to adjust the medication schedule to accommodate the resident's appointments. The facility's policy required medications to be administered within a specific time frame and for staff to document any deviations, but these procedures were not consistently followed.
Delay in Laboratory Result Causes Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure timely receipt and communication of a laboratory trough level result for a resident who was receiving intravenous vancomycin for acute osteomyelitis of both ankles and feet. The resident was admitted with an infected foot ulcer and had a physician's order for daily vancomycin infusions, which required a vancomycin trough level to be obtained and resulted before continuing the antibiotic therapy. The laboratory test was drawn as ordered, but there was a delay in receiving the results from the laboratory, which led to the resident missing four consecutive vancomycin infusions. Documentation in the Medication Administration Record and interdisciplinary notes indicated that the vancomycin doses were held each day due to the pending trough result, despite multiple follow-up calls to the laboratory by the DON. The laboratory reported being behind, and the result was not available until two days after the sample was collected. Both the DON and the attending physician confirmed their expectation that the result should have been available sooner, and the pharmacy also required the trough result before dispensing the medication. This delay in obtaining and communicating the laboratory result directly led to the interruption of the resident's prescribed antibiotic therapy.
High Medication Error Rate and Policy Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 32% error rate during the survey. Two residents were directly affected by these errors. Resident R6 received a Folic Acid supplement despite the order being discontinued on December 9, 2024. Additionally, five medications for R6 were administered more than 60 minutes after the scheduled time, which could potentially disrupt the prescribed administration intervals. Resident R7 was also affected by medication errors. The resident was observed receiving two sprays of Fluticasone Propionate in each nostril, contrary to the order of one spray per nostril. Furthermore, a blood pressure medication was administered more than an hour after the scheduled time, which could affect the medication's efficacy and the resident's health. The facility's policy on medication administration was found to be vague, lacking specific guidelines on the timing of medication administration. The Director of Nursing acknowledged the absence of a clear policy and stated that nurses are expected to administer medications within one hour before or after the scheduled time. However, the facility did not have a formal policy to guide nurses on this practice, contributing to the high medication error rate observed.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to provide adequate pain management for two residents, R16 and R44, as observed during a survey. R16 did not receive the prescribed topical pain relief medication as ordered by the physician, and there were incomplete pain assessments and evaluations of the effectiveness of pain interventions. Specifically, R16 was observed expressing pain and concern about upcoming physical therapy, yet the LPN did not conduct a comprehensive pain assessment, nor was the topical medication applied correctly. The medication was documented as administered, but it was applied to the back instead of the leg as ordered, and there was no documentation of pain levels or assessments before or after medication administration. R44 also experienced inadequate pain management, with incomplete pain assessments and evaluations of medication effectiveness. Despite receiving pain medications such as Robaxin and Hydrocodone, there was a lack of documentation regarding the numerical pain scale and re-evaluation of pain assessments. The surveyor noted discrepancies in the medication records, with more doses of Hydrocodone documented on the controlled drug receipt form than on the medication record, indicating a lack of proper documentation and monitoring of pain management. The facility's policy on pain assessment and management outlines the need for comprehensive pain evaluations and consistent monitoring, which were not adhered to in these cases. The surveyor's findings highlight a failure to follow the facility's pain management procedures, resulting in inadequate pain relief and documentation for the residents involved.
Medication Dispensing and Equipment Labeling Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing of medications for two residents, R44 and R369. For R44, there was a discrepancy between the Medication Administration Record (MAR) and the controlled medication narcotic count sheet. R44 was prescribed Hydrocodone 10/325 mg but was receiving Hydrocodone 5/325 mg instead, which did not provide adequate pain relief. This issue persisted from July 10, 2024, until it was corrected after R44 brought it to the staff's attention. Additionally, R44's MAR did not accurately reflect the administration of Protonix, which was supposed to be given 30 minutes before meals but was administered after meals instead. R44, who has diagnoses including Multiple Sclerosis and Gastro-Esophageal Reflux Disease (GERD), reported these discrepancies to the surveyor. The surveyor noted that the MARs provided by the facility showed inconsistencies in the administration of Hydrocodone, with some doses not administered on specific dates and others given in incorrect amounts. The Director of Nursing (DON) was unable to provide an explanation for the discrepancies between the MAR and the narcotic count sheet during the survey. For R369, the issue involved the labeling of personal medical equipment. The surveyor observed that R369's personal glucose monitor was not properly labeled with the resident's name, only with a room number, which was not R369's room number. This lack of proper identification could lead to potential errors in the use of medical equipment. The LPN responsible for medication administration confirmed the labeling practice but assured the surveyor that they knew which monitor belonged to R369.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care according to professional standards and the comprehensive person-centered care plan for two residents, R13 and R25. R13 was admitted with a left ankle fracture and surgical pin sites, requiring specific wound care as per hospital discharge instructions. However, the facility delayed the initiation of treatment for R13's left extremity and heel wound, starting two days after admission. The facility also did not follow the hospital's recommended treatment for pin sites, using betadine instead of the prescribed saline and hydrogen peroxide solution. Furthermore, there were significant gaps in the documentation of wound assessments for R13, with no assessments for the left heel after April 5, 2024, the left upper thigh after April 1, 2024, and no assessments for the left ankle pin site. R13 was eventually transferred to the hospital with severe sepsis. For R25, the facility failed to complete neurological checks following an unwitnessed fall, as per their policy. R25, who had multiple medical conditions including Type 1 Diabetes Mellitus and a history of kidney and pancreas transplants, experienced a fall on June 30, 2024. The facility's policy required neuro checks to be conducted for 72 hours following an unwitnessed fall, but the documentation was incomplete. Only two 15-minute and two 30-minute neuro checks were completed, instead of the required four each. Additionally, there were missing checks for July 1, 2024, and incomplete documentation for subsequent days. The deficiencies in care for both residents highlight a failure in adhering to established protocols and ensuring timely and appropriate treatment. The lack of proper documentation and follow-through on medical orders and assessments contributed to the inadequate care provided to R13 and R25, resulting in significant health risks for the residents involved.
Inadequate Supervision and Safety Measures Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents, leading to multiple injuries. One resident, who was admitted with several diagnoses including dementia and anxiety disorder, sustained multiple injuries of unknown origin, including bruising to the eyes, a laceration requiring stitches, and fractures. The facility did not thoroughly investigate these injuries or assess potential safety concerns, such as the condition of the resident's Broda chair, which was missing caps and had sharp edges. Despite the resident's history of osteopenia, the facility did not implement adequate preventive measures to avoid further injuries. Another resident, with a history of significant fall risk, experienced an unwitnessed fall while attempting to reach a Gatorade. The facility's intervention was to provide a reacher, but the reacher was not consistently accessible to the resident, as observed by the surveyor over several days. Additionally, there was no documented RN assessment to rule out injuries after the fall, indicating a lack of proper follow-up and supervision. A third resident, who was non-weight bearing and required a Hoyer lift for transfers, was improperly transferred by a single CNA, resulting in a fall. The facility's investigation did not address why the CNA transferred the resident alone, nor did it ensure adherence to the care plan that required two-person assistance for transfers. These deficiencies highlight the facility's failure to provide adequate supervision and implement necessary safety measures to prevent accidents and injuries.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to the development and deterioration of pressure injuries. One resident, who was on hospice care, developed a stage 1 pressure ulcer on the coccyx, which was not assessed or treated by the facility's wound care doctor despite hospice's request. The resident's air mattress was incorrectly set for a much higher weight than the resident's actual weight, and no care plan revisions were made following the development of pressure areas. The facility also failed to document weekly skin checks and did not obtain physician orders for wound care treatments. Another resident was identified with an unstageable pressure injury on the left buttock, and the facility did not observe turning and repositioning as per the care plan. Treatments were not completed, and the care plan did not include approaches for repositioning until after the pressure injury was identified. The resident's pressure injury assessments showed a progression from unstageable to stage 3, with no evidence that the physician was notified of the pressure injury. A third resident had a deep tissue injury on the left heel, but the facility did not revise the care plan or implement treatment until two days later. During the survey, no heel boots were observed in place, and there was no assessment conducted on a specified date. The facility's failure to follow its own policy on pressure injury prevention and treatment, including timely assessments and care plan updates, contributed to the deficiencies identified by the surveyors.
Sanitation Deficiencies in Food Service and Dish Machine Operations
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a sanitary manner, which had the potential to affect all 47 residents. During observations, a Food Service Associate (FSA) was seen preparing and serving food without wearing a beard net, despite having an evident beard. This was in violation of the facility's policy that requires all associates working with food to restrain facial hair with a beard net. The lack of adherence to this policy was confirmed by the Food Service Supervisor (FSS), who acknowledged that the FSA should have been wearing a beard net. Additionally, the facility's low temperature dish machines were not reaching the required minimum temperature of 120°F as per the facility's policy, and the manufacturer's guidelines indicated a minimum of 140°F. Observations showed that the dish machines on both the 2nd and 3rd floors consistently failed to reach these temperatures. Furthermore, the FSAs were not using test strips to verify the concentration of the sanitizer solution, which is necessary to ensure proper sanitation. The logs for dish machine temperatures and sanitizer concentrations were found to be incomplete and inaccurate, with repeated entries of 100 ppm for the chlorine rinse, suggesting a lack of proper monitoring and documentation. The surveyor noted that there was no managerial oversight, as evidenced by the absence of weekly review signatures on the dish machine logs. This lack of oversight contributed to the ongoing issues with dish machine temperatures and sanitizer testing. The facility's failure to adhere to its own policies and the manufacturer's guidelines for dish machine operation, along with the lack of proper food handling practices, constituted a significant deficiency in maintaining sanitary conditions for food service.
Inadequate Infection Control and Prevention Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies identified during the survey. The Water Management Plan (WMP) was not updated to reflect changes in program members, did not include the Infection Preventionist (IP), and lacked revisions after the closure of a facility wing. Additionally, the WMP did not have a defined flush program for little-used outlets, logs to monitor water temperatures, or include eye washing stations and ice machines in its risk assessment. There was also a failure to measure and record residual disinfectant levels. The facility's surveillance of the infection control program was inadequate, lacking a defined policy for staff illness, a list of reportable communicable diseases, and a system for addressing increased infection rates. The facility's infection surveillance was found to be lacking, with no policy for staff illness procedures and no documentation of increased infection rates or interventions implemented. The surveillance data did not separate urinary tract infections (UTIs) into catheter-associated and non-catheter-associated infections. During interviews, it was revealed that the Director of Nursing (DON) and the Infection Preventionist (IP) were not adequately tracking or trending infection data, and there was no documentation of interventions for increased UTI rates. Additionally, the facility's response to a COVID outbreak was incomplete, with missing documentation of health department recommendations, restriction of admissions, and emergency meetings with the infection control committee. The facility also failed to adhere to proper infection control practices, as observed in the handling of personal protective equipment (PPE) and urinary catheter bags. Staff did not wear appropriate PPE when providing care to a resident on Enhanced Barrier Precautions, and hand hygiene was not consistently performed. Furthermore, a resident's urinary catheter bag was repeatedly observed on the floor, uncovered, and not handled hygienically by staff. These observations indicate a lack of adherence to the facility's policies and procedures for infection control, contributing to the overall deficiency in maintaining a safe environment for residents.
Failure to Complete and Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required 92 days for six residents. The surveyor identified that the MDS assessments for residents R27, R5, R44, R29, R25, and R50 were not completed and submitted on time. The delay was attributed to the facility's computer system being inaccessible from May 8, 2024, to June 24, 2024, during which the RN/MDS-G responsible for completing the assessments was not present at the facility. As a result, several MDS assessments were pending completion and submission. The surveyor's investigation revealed that the RN/MDS-G was working on completing the overdue MDS assessments, with a target completion date of July 31, 2024, coinciding with the transition to new facility ownership. The RN/MDS-G indicated that approximately 30 MDS assessments, mostly quarterly and discharges, were still pending. The surveyor noted that the facility's Emergency Preparedness plan did not include specific instructions for completing and submitting MDS assessments during electronic medical record (EMR) downtime. The surveyor reviewed the facility's EMR Disaster and Downtime Process, which outlined general procedures for handling unanticipated EMR downtime but lacked guidance on MDS completion. The surveyor confirmed that the MDS assessments for residents R25 and R29 were completed and submitted during the recertification survey. Despite the facility's submission of additional documentation, the concerns regarding the timely completion and submission of MDS assessments remained unresolved.
Failure to Act on Pharmacist Recommendations in Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review and reported any irregularities to the attending physician, medical director, and director of nursing for five residents. The facility's policy requires that any irregularities noted during the medication regimen review (MRR) be reported and addressed promptly, with physician responses documented in the resident's medical record. However, the surveyor found that the MRRs for residents R5, R42, R25, R18, and R11 were either missing, not signed, or not acted upon by the physician. For resident R5, the surveyor was unable to locate pharmacist notes for several months, and the MRRs provided were not signed or dated by the physician. The MRRs contained recommendations for medication adjustments, such as adding a stop date for Lorazepam, but there was no evidence of physician response or action. Similarly, for resident R42, the MRRs recommended adding pantoprazole for gastroprotection and adjusting insulin orders, but these recommendations were not promptly acted upon by the physician. Residents R18 and R25 also had MRRs with recommendations for medication adjustments that were not reviewed or acted upon by the physician. For R18, the pharmacist recommended evaluating and potentially increasing the dosage of Sertraline, while for R25, the pharmacist suggested monitoring for involuntary movements and considering a dose reduction for Mirtazapine. Additionally, for resident R11, the surveyor noted that several months of pharmacy reviews were not signed or dated by the physician, indicating a lack of review and action on the pharmacist's recommendations.
Failure to Involve Resident in Care Planning Leads to Anxiety
Penalty
Summary
The facility failed to ensure that a resident, identified as R44, was given the opportunity to participate in the development and implementation of her person-centered care plan, particularly concerning her personal belongings. R44, who has diagnoses including multiple sclerosis, hypertension, anxiety, and blindness in the left eye, was assessed as having modified independence for cognitive skills and was independent with her activities of daily living. Despite this, the facility did not involve her in decisions regarding the handling of her personal items, leading to an incident where her belongings were removed from her room without her consent. The incident occurred when R44 was taken to the shower, and upon returning, she discovered that several personal items, including Styrofoam bowls, a robe, and two dollar bills, were missing. The resident expressed that she felt violated and anxious about staff entering her room without her knowledge. The facility's social worker acknowledged the incident and apologized to R44, but the care plan was not updated to address her anxiety and concerns about staff entering her room until after the surveyor's intervention. The surveyor's observations and interviews with staff and the resident revealed that R44 was not comfortable leaving her room due to fear of her belongings being taken. The facility's failure to involve R44 in her care planning and to respect her personal space contributed to her anxiety and reluctance to participate in activities outside her room. The deficiency was noted as the facility did not develop a care plan with R44's participation to address her concerns and reduce her anxiety about staff entering her room and handling her belongings.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for a resident, identified as R29, to the State Survey Agency. R29, who was admitted with diagnoses including heart failure, dementia, and anxiety disorder, was noted to have multiple injuries over a period of time. On May 2, 2024, bruising was observed on R29's left eye and breast, and on May 16, 2024, additional bruising was noted on the right eye and foot, along with a laceration between the toes. Despite these injuries, which included a fractured toe and required stitches, the facility did not report them as required by their policy. The facility's policy mandates that all injuries of unknown origin be promptly reported to appropriate authorities. However, the facility's investigation concluded that the injuries were self-inflicted or due to equipment issues, such as a missing cap on a Broda chair. The Nursing Home Administrator (NHA) and Director of Nursing (DON) attributed the injuries to R29's combative behavior and osteoporosis, without sufficient evidence or documentation to support these claims. The facility's failure to report these injuries was highlighted during a surveyor's investigation, which noted the lack of documentation and reporting to the state agency. The surveyor's interviews and record reviews revealed that the facility did not adhere to its own policy of reporting injuries of unknown origin. Despite the presence of multiple injuries and the resident's inability to explain them, the facility did not submit the required reports to the state agency. The surveyor expressed concerns about the facility's handling of the situation, noting that the injuries met the definition of unknown origin and should have been reported accordingly.
Failure to Investigate Resident Injuries
Penalty
Summary
The facility failed to ensure that all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated. Specifically, the facility did not conduct a comprehensive investigation into the injuries of a resident, identified as R29, who was found with multiple bruises and fractures of unknown origin. The facility's policy required that all such incidents be promptly reported and thoroughly investigated, but this was not adhered to in the case of R29. R29, who was admitted with diagnoses including heart failure, dementia, and anxiety disorder, was noted to have bruising on multiple occasions, as well as a fractured toe and a laceration requiring stitches. Despite these injuries, the facility did not report them to the state survey agency or complete a thorough investigation. The facility's documentation was insufficient, with only one staff statement attributing the bruising to R29 holding a babydoll tightly, and no comprehensive investigation into the cause of the injuries was conducted. The facility's failure to investigate was further highlighted by the lack of documentation and reporting of the injuries to the state agency. The facility's explanations for the injuries, such as attributing them to self-infliction or the resident's osteoporosis, were not substantiated with thorough investigations or evidence. The surveyor noted that the facility did not provide documentation of resident interviews or signed staff statements, indicating a lack of compliance with their own policies and procedures for handling such incidents.
Failure to Notify HCPOA and Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to notify a resident's Health Care Power of Attorney (HCPOA) and primary physician of significant changes in the resident's condition and status. The resident, who was admitted with diagnoses including heart failure, dementia, and anxiety disorder, was receiving hospice care and had an activated HCPOA. Despite this, the facility did not inform the HCPOA or the primary physician about the resident's transfer to the emergency room for an x-ray, the development of a stage 1 pressure ulcer, or the non-administration of scheduled pain medications. The report highlights multiple instances where the facility did not adhere to its policy of notifying relevant parties about changes in the resident's condition. The resident experienced several injuries, including bruising and a laceration that required medical attention, yet there was no documentation of notification to the primary physician or HCPOA. Additionally, the resident's scheduled morphine doses were not administered on several occasions, and the primary physician was not consulted about this deviation from the prescribed treatment plan. The surveyor's findings indicate a lack of communication and documentation regarding the resident's care, which is contrary to the facility's policy. The facility's failure to notify the HCPOA and primary physician of significant changes, such as the development of a pressure ulcer and the resident's transfer to the emergency room, demonstrates a deficiency in the standard of care expected in such situations.
Failure to Complete Timely MDS Assessments Due to EMR Downtime
Penalty
Summary
The facility failed to complete a comprehensive annual Minimum Data Set (MDS) assessment for two residents, R18 and R21, within the required regulatory timeframe. R18's annual MDS was due on May 15, 2024, but was not completed and submitted until July 18, 2024, during the recertification survey. Similarly, R21's annual MDS was due on May 8, 2024, but was not completed and submitted until July 15, 2024. This delay resulted in the absence of timely annual comprehensive assessments, which are necessary for reviewing and updating care plans based on the residents' current needs. The facility's failure to complete these assessments in a timely manner was attributed to a lack of access to electronic medical records (EMR) from May 8, 2024, to June 28, 2024, during which the MDS Registered Nurse (RN-G) was working at another facility. The surveyor's investigation revealed that the facility did not have a documented process for completing and submitting MDS assessments during EMR downtime. Although the facility had an EMR Disaster and Downtime Process, it did not include instructions for handling MDS assessments. The Nursing Home Administrator acknowledged that the MDS assessments should have been completed on paper during the downtime. The facility's failure to address this gap in their emergency preparedness plan contributed to the delay in completing the MDS assessments for R18 and R21, as well as approximately 30 other assessments from May and June.
Failure to Ensure Privacy and Dignity for Resident with Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and was provided dignity. The resident, who was admitted with a urostomy and a PICC line for antibiotic administration, was observed multiple times with their catheter bag visible from the hallway and not covered in a privacy bag. Despite the resident's intact cognition and ability to communicate, the care plan was not updated to reflect the resident's preference regarding the visibility of the catheter bag. The surveyor noted the presence of hematuria in the catheter bag during observations, which the resident attributed to a recent urostomy placement and ongoing antibiotic treatment for a major infection. The surveyor discussed the observations with the unit manager and the director of nursing, who acknowledged the concern. It was revealed that a family member of the resident preferred the catheter bag to remain uncovered for visibility. However, the facility did not revise the care plan to document the resident's own preference on this matter, which is a lapse in ensuring the resident's dignity and privacy. The facility's inaction in updating the care plan to reflect the resident's wishes led to the deficiency noted by the surveyor.
Deficiency in Respiratory Care for Resident
Penalty
Summary
The facility failed to ensure that necessary respiratory care services were consistent with professional standards of practice for a resident requiring continuous oxygen therapy. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia, was observed with unlabeled oxygen tubing and a dry humidification jar on multiple occasions. The facility's policy on oxygen administration requires that the humidifier bottle and oxygen tubing be labeled and dated, and that the water level in the humidifying jar be checked periodically to ensure it is sufficient. However, during the survey, the resident's oxygen tubing was not labeled, and the humidification jar was found to be dry and not dated, indicating a lapse in adherence to the facility's policy. The resident's treatment administration record indicated that the tubing and humidification were last changed several days prior to the survey, with the next change scheduled for a future date. Despite this schedule, the humidification jar was observed to be empty, and the tubing remained unlabeled. The unit manager acknowledged the concerns raised by the surveyor and confirmed that the night shift was typically responsible for changing the tubing and humidification. The nursing home administrator also acknowledged the surveyor's concerns, indicating an awareness of the deficiency in providing appropriate respiratory care for the resident.
Lack of Stop Date and Rationale for PRN Ativan Order
Penalty
Summary
The facility failed to ensure that a resident did not receive unnecessary psychotropic medications, specifically Ativan, without a proper stop date or documented rationale for extending the PRN order beyond 14 days. The resident, who was admitted with multiple diagnoses including anxiety disorder and depression, had an order for Ativan 0.5 mg every eight hours as needed, but there was no stop date or physician's rationale documented for extending the PRN order. The facility's policy requires that any PRN psychotropic medication order extended beyond 14 days must have a documented rationale and specific duration indicated by the practitioner. During the survey, it was noted that the resident's Ativan order lacked a stop date, and the physician's progress notes did not address the continuation of the PRN Ativan. The RN/UM indicated that the hospice team was responsible for the medication orders, but there was no communication or documentation from the hospice team regarding the rationale for the extended use of Ativan. The surveyor informed the NHA and DON of the deficiency, highlighting the absence of a stop date and documented rationale for the PRN Ativan order.
Failure to Provide Routine Dental Care to Resident
Penalty
Summary
The facility failed to assist a resident, identified as R25, in obtaining routine dental care, which was necessary due to the resident's poor oral health condition. R25, who was admitted with multiple medical diagnoses including rhabdomyolysis, type 1 diabetes mellitus, and kidney and pancreas transplants, had a Brief Interview for Mental Status (BIMS) score indicating moderately impaired decision-making skills. Despite having only 4-5 blackened teeth and expressing a desire to see a dentist for potential denture fitting, R25 was not offered dental services since admission. The facility's policy requires that dental services be available and documented, but there was no care plan addressing R25's dental needs, and no record of R25 being on the dental list. Interviews with facility staff revealed a lack of communication and documentation regarding R25's need for dental services. The social worker and medical records personnel were unaware of R25's dental needs, and the admission coordinator confirmed that individual consents for dental services were not obtained. The nursing home administrator acknowledged the oversight, noting a change in leadership, but stated that dental services are typically offered within six months of admission. The deficiency was only addressed after the surveyor brought it to the facility's attention, highlighting a failure to adhere to the facility's policy and impacting R25's quality of life.
Failure to Provide Assistive Eating Equipment
Penalty
Summary
The facility failed to provide special assistive eating equipment for a resident, identified as R40, who required assistance due to medical conditions including Parkinson's Disease, weakness, protein-calorie malnutrition, and dysphagia. Despite being cognitively intact with a BIMS score of 15, R40 needed partial to moderate assistance with eating. The resident's nutrition risk assessment indicated a need for special utensils and cups, but these were not provided. Observations by the surveyor revealed that R40 struggled to eat independently due to shaky hands and was unable to use the standard metal utensils and foam cup with a straw provided. Interviews with facility staff, including a CNA, Unit Manager, Dietary Aide, and DON, highlighted a lack of awareness and communication regarding R40's need for special eating equipment. The CNA and Unit Manager acknowledged R40's need for assistance, particularly with meals requiring utensils. However, the dietary assessment note recommending special utensils was not seen by the DON until pointed out by the surveyor. The Speech Therapist, who had evaluated R40, confirmed the need for a mechanical soft diet initially, which was later upgraded. The deficiency was evident when R40's meal was left untouched due to the lack of appropriate assistive devices and assistance, as observed by the surveyor.
Deficiency in Hospice Service Coordination
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for two residents, R5 and R29, as identified during a survey. For R5, hospice visit notes were missing from both the medical record and the hospice binder located at the nurse's station. Despite having a hospice care plan in place, there was confusion among staff regarding the schedule and presence of hospice staff, as well as the identity of the hospice liaison. Interviews with various staff members, including registered nurses and the Director of Nursing, revealed a lack of awareness and communication about hospice visits and documentation. For R29, the facility did not complete the recertification of terminal illness, and there was no list of assigned hospice staff with contact information available. The hospice binder lacked a schedule of hospice staff visits, and the facility staff were unaware of a designated liaison for hospice communication. Interviews with hospice staff and facility nurses indicated that communication forms were not consistently placed in the hospice binder, leading to care issues not being addressed timely or at all. The facility's obligations under the Nursing Facility Services Agreement with the hospice provider were not met, as there was no designated liaison to coordinate care between the facility and hospice. The agreement required the facility to ensure comfort and care for hospice patients and to work with hospice to develop and maintain a care plan. However, the lack of communication and coordination between the facility and hospice staff resulted in deficiencies in the provision of hospice services for both residents.
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Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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