Wisconsin Rapids Health Services
Inspection history, citations, penalties and survey trends for this long-term care facility in Wisconsin Rapids, Wisconsin.
- Location
- 1350 River Run Dr, Wisconsin Rapids, Wisconsin 54494
- CMS Provider Number
- 525212
- Inspections on file
- 35
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Wisconsin Rapids Health Services during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions and improper food storage in a second-floor kitchenette used for resident meal service. Mouse droppings were observed in multiple cabinets under and beside the sink, along with several mouse traps, despite prior pest control visits documenting droppings in the same area. The Maintenance Director and Housekeeping Supervisor acknowledged an ongoing mouse problem, and the Dietary Manager confirmed there was no documented schedule for cleaning cabinet interiors as required by facility policy. In the same kitchenette refrigerator, surveyors found multiple resident and family food items that were unlabeled, undated, and/or past their best-by or use-by dates, including condiments, beverages, sandwiches, and cream pie, contrary to the facility’s policy requiring labeling and timely disposal of prepared foods.
A resident with moderate cognitive impairment was allegedly yelled at by a CNA after triggering an alarm, as reported by the resident's spouse. The incident was documented and internally investigated, but the facility did not report the allegation of verbal abuse to the State Agency as required by policy.
A resident with moderate cognitive impairment was allegedly yelled at by a CNA after an alarm was triggered, as reported by the resident's spouse. The facility did not conduct a thorough investigation into the verbal abuse allegation, failing to interview involved parties or provide follow-up, contrary to its abuse policy.
Two residents did not receive safe and accurate medication administration when a nurse failed to properly administer and document Ozempic injections, including compensating for a leaking dose without proper documentation, and another nurse recorded a dose as given when it was not administered. Additionally, a nurse did not follow correct technique when administering insulin with a pen, removing it too quickly from a resident's skin.
A resident with significant mobility limitations was unable to transfer out of bed for several days due to a bariatric Hoyer lift being out of service. Staff had been sharing remotes between two bariatric lifts for weeks because of a malfunction, and maintenance checks were not consistently documented. There was confusion among staff about which lifts were operational, and the lack of timely reporting and resolution of equipment issues led to the deficiency.
A resident with multiple complex medical conditions experienced repeated meal refusals and poor oral intake over several days, but the facility did not notify the physician as required by policy. Staff and nurse practitioners confirmed that notification should have occurred after multiple consecutive meal refusals. The physician was only notified after the resident showed acute signs of decline and dehydration, resulting in hospitalization.
Staff failed to follow infection prevention protocols during care for two residents, including not performing hand hygiene between glove changes, touching multiple surfaces with soiled gloves, and not wearing required PPE such as gowns during high-contact activities for a resident on enhanced barrier precautions for MRSA. Hand sanitizer was not accessible in resident rooms, and staff expressed confusion about which infection control signage to follow.
A resident with moderate cognitive impairment and an activated POAHC received a COVID-19 vaccine without a signed consent form in the medical record, as required by facility policy. Staff obtained verbal authorization from the POAHC and later from the resident, but failed to secure and document the necessary signed consent prior to vaccine administration.
A facility failed to investigate and resolve a grievance regarding medication administration for a resident during a respite stay. Despite the facility's policy, the grievance was not addressed, and no resolution was provided. The resident's medical record indicated medications were administered, but inconsistencies were found in staff interviews and documentation. The facility did not follow its grievance process, leading to the deficiency.
Two residents in an LTC facility experienced inadequate pressure ulcer care, leading to the development and worsening of pressure injuries. One resident, admitted with a sacral pressure injury, developed multiple unstageable pressure injuries due to delayed care planning and intervention. Another resident with stage IV pressure injuries did not receive consistent care, missed wound clinic appointments, and was not repositioned as required. The facility's failures in care planning, intervention, and communication resulted in actual harm to the residents.
The facility failed to maintain a clean and sanitary environment for food preparation, affecting over 75% of residents. Missing documentation in sanitization logs and refrigerator temperatures was noted, indicating non-compliance with FDA guidelines. This included missing records of sanitizing solution concentration and cold storage temperatures over several months.
The facility failed to notify the State Long Term Care Ombudsman about hospital transfers for four residents, despite multiple hospitalizations for various medical conditions. Documentation of these notifications was absent, and the facility's communication only included admissions, discharges, and deaths, omitting the required hospital transfer notices.
A long-term care facility failed to maintain an effective infection prevention and control program, with staff not adhering to PPE and hand hygiene protocols. Staff were observed providing care to residents on enhanced barrier and contact precautions without proper PPE, and hand hygiene practices were inadequate during personal and wound care. These deficiencies increased the risk of infection transmission among residents.
A resident with cardiomyopathy ischemic, hypertension, and congestive heart failure was admitted to Hospice services, but the facility failed to complete a Significant Change in Status MDS assessment within the required timeframe. The DON confirmed the oversight, and the facility lacked a policy on Significant Change MDS assessments.
A resident with multiple medical conditions was admitted and later discharged without a baseline care plan being developed and implemented within 48 hours, as required. The DON confirmed the oversight during an interview but could not provide the necessary documentation.
Two residents in an LTC facility were found to have incomplete care plans. One resident, prescribed trazodone for insomnia, lacked a sleep hygiene care plan with non-pharmacological interventions. Another resident with venous insufficiency had no comprehensive care plan for skin integrity, as the previous plan was resolved and not replaced. These deficiencies were confirmed by the DON during a survey.
A resident discharged from the facility did not receive a discharge summary with a recapitulation of stay. The resident, admitted with multiple diagnoses including orthopedic aftercare and diabetes, left the facility before completing skilled services. The surveyor found no recapitulation in the medical record, and the DON confirmed it was not completed as expected.
A resident receiving enteral feeding had their feeding tube placement inadequately verified, leading to a deficiency. The resident, with dysphagia and esophageal obstruction, required gastrostomy tube feeding. A nurse administered a flush without checking the tube's placement as per facility policy, relying instead on listening for a 'whoosh' sound. This action was contrary to the protocol of verifying external markings and tube length, as observed by a surveyor.
A facility failed to follow proper procedures for insulin administration, as a nurse used an insulin syringe to draw insulin from a pre-filled pen, contrary to guidelines. A resident expressed concerns about blood sugar control, and the DON and pharmacist were unaware of this practice, which was not supported by facility policy or external guidelines.
A facility failed to comprehensively assess a resident prescribed trazodone for insomnia, lacking a sleep hygiene care plan and non-pharmacological interventions. No sleep behavior monitoring was documented to evaluate the medication's effectiveness. The DON confirmed the last sleep assessment was incomplete, and routine checks did not document the resident's sleep status, leading to the deficiency.
The facility did not ensure residents were treated with dignity during meals, as observed with two residents. A CNA stood while feeding a resident with Alzheimer's and another with Parkinson's, contrary to their care plans. The DON confirmed staff should be seated when assisting with meals, highlighting a breach in the facility's dining policy.
The facility failed to maintain sanitary food storage and proper labeling practices. Various undated, unlabeled, or expired food items were found in the kitchenettes, and two thawed, undated shakes were observed on a medication cart. Staff acknowledged the disorganization and lack of cleanliness, with dietary aides responsible for dating and cleaning. This posed a potential risk to residents' safety.
The facility failed to provide timely assistance with ADLs for three residents. One resident did not receive scheduled showers, another did not receive consistent diabetic nail care, and a third experienced a 26-minute delay in call light response. The facility's policies were not adequately followed, leading to these deficiencies.
The facility failed to provide adequate care for two residents with pressure injuries. One resident did not receive proper hand hygiene during wound care, and pressure-relieving measures were not consistently implemented, leading to the deterioration of existing wounds. Another resident's care plan to float heels and use heel lift boots was not consistently followed, as the resident's heels were in direct contact with the mattress. The facility's lapses in protocol and documentation contributed to these deficiencies.
Two residents in the facility did not receive appropriate respiratory care. One resident was given CPAP therapy without a physician's order and lacked the necessary BiPAP equipment, while another resident had a CPAP order but no corresponding care plan. Interviews confirmed these deficiencies in respiratory care management.
A resident received incorrect medication due to a transcription error, leading to the administration of triple antibiotic ointment instead of the prescribed triamcinolone ointment. The resident also missed several doses of the correct medication and experienced a reaction to it, which was not properly documented or communicated.
Unsanitary Kitchenette Conditions and Improper Food Storage
Penalty
Summary
The facility failed to ensure food was stored in a safe and sanitary manner and that the kitchenette and related food service areas were maintained in a clean condition, affecting residents on the second floor who used that dining area. Surveyors observed mouse droppings in two cabinets in the kitchenette adjacent to the second-floor dining room, including under the sink and in a cabinet to the left of the sink, along with several mouse traps on the floor and inside the cabinet. Pest control records showed prior findings of mouse droppings in the same kitchenette area and the placement of bait stations, as well as a note advising cleanup of mouse droppings. The Maintenance Director and Housekeeping Supervisor acknowledged there had been a mouse problem and that several mice had been caught. The Dietary Manager confirmed there was no cleaning schedule documenting when the interior of the cabinets was last cleaned and was unsure whether the droppings were new or old, despite facility policy requiring cleanliness and sanitation of dining and food service areas through a written, comprehensive cleaning schedule. The facility also failed to ensure that food stored in the kitchenette refrigerator was properly labeled, dated, and discarded in accordance with policy, which required prepared food brought in by families or visitors to be labeled with content and date, consumed within three days, or disposed of by staff. During inspection of the refrigerator, surveyors found multiple items that were unlabeled, undated, and/or past their best-by or use-by dates, including resident-labeled apple butter, salad dressings, jam, pickles, apple cider, an undated meat and lettuce sandwich, another unlabeled sandwich, and undated cream pie pieces labeled with a resident’s name. The Dietary Manager stated that residents and families use the refrigerator and kitchen items and that it was everyone’s responsibility to ensure items were labeled, dated, and expired items discarded, and confirmed that the observed expired and unlabeled items should have been labeled and/or disposed of.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Agency as required by its Abuse, Neglect, and Exploitation policy. On 9/3/25, a resident (R8) reported that a Certified Nursing Assistant (CNA-E) yelled at another resident (R7), who was R8's spouse, after an alarm was triggered when R7 attempted to get a remote while in a wheelchair. The incident was documented as a grievance, and the Nursing Home Administrator (NHA-A) conducted an internal investigation. However, there was no follow-up or confirmation of the incident, and the facility did not report the allegation to the State Agency within the required timeframe. R7, the resident involved, had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, and was assessed to have moderate cognitive impairment. R8, the reporting resident, was not cognitively impaired. Despite the facility's policy requiring all alleged violations to be reported to the Administrator and State Agency within specified timeframes, the NHA-A did not report the incident, citing personal knowledge of the individuals involved and a belief that the CNA's tone was misinterpreted. The deficiency was confirmed during a surveyor interview with the NHA-A.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with moderate cognitive impairment. According to the report, a grievance was filed by another resident, who is the spouse of the alleged victim, stating that a CNA yelled at the resident after an alarm was triggered when the resident attempted to get a remote while in a wheelchair. The facility's policy requires immediate and thorough investigation of any abuse allegations, including interviews and documentation. However, the investigation was not comprehensive; staff did not confirm or deny the incident, and there was no follow-up or further information documented. The Nursing Home Administrator acknowledged that a thorough investigation was not completed and attributed the incident to a possible misinterpretation of the CNA's tone. The administrator also confirmed that no resident or staff interviews were conducted as part of the investigation, and there was no staff education provided regarding the incident. The lack of a complete investigation did not align with the facility's abuse policy, which mandates prompt and thorough response to all allegations of abuse.
Failure to Ensure Safe and Accurate Medication Administration
Penalty
Summary
Two residents experienced deficiencies in the administration of medications as prescribed. One resident, with diagnoses including type 2 diabetes, morbid obesity, and chronic kidney disease, had an order for Ozempic to be administered subcutaneously once weekly. On one occasion, a registered nurse observed medication leaking from the injection site and attempted to compensate by administering an additional amount, but did not document the altered dose or notify the provider or facility administration. On a subsequent occasion, another nurse did not have the medication available to administer, yet the medication administration record incorrectly indicated that the dose had been given. The nurse verbally communicated the missed dose, but the documentation did not reflect the actual event, leading to inaccurate records regarding medication administration. Another resident, with diagnoses including diabetes and severely impaired cognition, had an order for sliding scale Lispro insulin to be administered subcutaneously three times daily. During an observed medication pass, a registered nurse administered the insulin using an injectable pen but did not hold the pen to the resident's skin for the recommended duration, removing it in less than two seconds instead of the required five to ten seconds. This action was inconsistent with the facility's policy and the manufacturer's instructions for proper insulin pen use. These events were identified through observation, staff interviews, and record review, revealing failures to follow established medication administration protocols, accurately document medication administration, and ensure that medications were administered as ordered for both residents.
Failure to Maintain Safe and Available Mechanical Lifts for Resident Transfers
Penalty
Summary
The facility failed to ensure that essential mechanical lifts were maintained in safe operating condition, directly affecting a resident who required a bariatric Hoyer lift for transfers. The resident, who had multiple diagnoses including morbid obesity, chronic respiratory failure, and limited mobility, was unable to transfer out of bed for a four-day period when the bariatric Hoyer lift was out of service. Staff interviews and record reviews confirmed that the resident required assistance from two staff members and a Hoyer lift with a specific sling for transfers to an electric wheelchair, as documented in the care plan. Prior to the lift becoming completely inoperable, staff had been sharing hand remotes between the bariatric Hoyer lift and a bariatric EZ stand lift for approximately two weeks because one of the remotes was not working. Maintenance staff were aware of the issue and had ordered a new remote, but there was a delay in receiving it. During this period, the facility's policy requiring mechanical lifts to be available and accessible 24 hours per day was not met, and routine checks and maintenance were not consistently documented, especially for rented equipment. Multiple staff members, including CNAs and LPNs, confirmed the lifts were not functioning and that there was confusion regarding which lifts were operational. The maintenance director acknowledged that inspections of rented lifts were not documented, and the nursing home administrator was not fully aware of the impact on the resident. Additionally, there was no staff education on timely reporting of equipment issues, contributing to the delay in resolving the deficiency.
Failure to Notify Physician of Change in Condition Due to Meal Refusals
Penalty
Summary
A deficiency occurred when the facility failed to notify a physician regarding a significant change in condition for a resident with multiple complex medical diagnoses, including paraplegia, protein-calorie malnutrition, and several pressure ulcers. The resident had a care plan identifying risk for nutritional status change and poor oral intake, with interventions to encourage and assist with food and fluid consumption. Despite this, the resident refused at least two meals per day on multiple days in March, with documentation showing several instances of consecutive meal refusals and poor intake, but there was no evidence that the physician was notified of these refusals as required by facility policy and the INTERACT Change in Condition tool. The resident's medical record indicated ongoing poor nutritional intake, with an average of 0-25% of meals consumed and multiple days where two or more meals were refused. On specific dates, the resident refused all meals or had five consecutive meal refusals, and fluid intake was also low or refused on some occasions. Staff interviews confirmed that the resident regularly refused meals, and both nurse practitioners interviewed stated they would have wanted to be notified if a resident refused five meals in a row. However, there was no documentation that such notification occurred prior to the resident's acute decline. The deficiency was further evidenced when the resident experienced a significant change in condition, including signs of dehydration, poor skin turgor, sunken eyes, and decreased responsiveness, which ultimately led to hospitalization. Only at this acute stage was the physician notified and action taken. The lack of timely physician notification regarding the resident's ongoing meal refusals and poor intake, as required by policy, contributed to a delay in medical assessment and intervention.
Failure to Maintain Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during the provision of care for two residents. In one instance, a certified nursing assistant (CNA) provided morning care to a resident with a seizure disorder and malnutrition who had urinated and had a bowel movement in bed. The CNA donned gloves but did not have wipes or a garbage can nearby, touched multiple surfaces with soiled gloves, and changed gloves four times without performing hand hygiene between changes. Hand sanitizer was not readily available in the resident's room, and the CNA acknowledged not performing hand hygiene during glove changes or after touching contaminated items. In another case, a resident with diabetes, MRSA, and cellulitis, who was on enhanced barrier precautions (EBP) due to venous wounds and a MRSA infection, was transferred from bed to toilet by a CNA and an LPN. Both staff members donned gloves but did not wear gowns as required by the EBP and contact precautions signage posted on the resident's door. The staff were observed transferring the resident without the appropriate PPE, and both later confirmed they did not follow the signage instructions, with the LPN expressing confusion about which sign to follow. The Director of Nursing (DON) confirmed that staff should perform hand hygiene when moving from dirty to clean tasks and when donning new gloves, and that gowns should have been worn during the transfer for a resident on EBP and contact precautions. The DON also acknowledged that hand sanitizer was not accessible in resident rooms and that infection control audits were primarily conducted on other shifts, not during the night shift when the deficiencies were observed.
Lack of Signed COVID-19 Vaccine Consent for Resident with POAHC
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a signed COVID-19 vaccination consent was present in the medical record for a resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC). The facility's policy required a signed consent prior to vaccine administration, but only verbal consent was obtained and documented for the COVID-19 vaccine. The registered nurse (RN) contacted the resident's POAHC by phone and received verbal authorization, then mailed a consent form for signature, which was not returned. The RN did not document the verbal conversation in the resident's medical record, and the POAHC later stated that authorization for all vaccines except COVID-19 was given, with the resident themselves authorizing the COVID-19 vaccine at a later date, despite the POAHC being activated for medical decisions. The Director of Nursing (DON) confirmed that the facility typically works off verbal consents and was unaware of the specific communication between the POAHC and the former DON. The resident's medical record contained a consent form indicating verbal consent, but lacked the required signed authorization as per facility policy. The deficiency was identified through interviews with staff and the POAHC, as well as review of the resident's medical record and facility policy.
Failure to Investigate and Resolve Medication Grievance
Penalty
Summary
The facility failed to promptly investigate and resolve a grievance regarding medication administration for a resident during a respite stay. The grievance, which was emailed to the facility, indicated that certain medications were not administered to the resident. Despite the facility's grievance policy requiring timely resolution, the grievance was not investigated, and no resolution was provided. The resident, who was admitted for a Hospice respite stay, had multiple diagnoses including congestive heart failure and end-stage renal disease. The medical record indicated that medications such as levothyroxine and furosemide were administered as ordered, but the medication administration record did not show any doses were refused or not administered. Interviews with nursing staff revealed inconsistencies in the medication administration process, with some staff recalling the use of pharmacy-supplied medications and others mentioning the possibility of using medications brought from home. The Director of Nursing and Social Worker were unable to provide documentation or evidence of the medications being at the facility or being administered. The Hospice provider's records indicated that the resident's family was concerned about medications not being administered, as the medications sent with the resident returned home unused. The facility did not follow its grievance process, and a thorough investigation was not completed, leading to the deficiency.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R151 and R32, leading to the development and worsening of pressure injuries. R151 was admitted with a sacral pressure injury and was assessed to be at risk for further pressure injuries. Despite this, the facility did not develop a care plan or implement necessary interventions to off-load pressure from R151's lower extremities and sacral wound until several days after admission. This delay resulted in the development of multiple unstageable pressure injuries. Observations revealed that R151's feet were not properly off-loaded, and heel protectors were not used as ordered, contributing to the deterioration of R151's condition. R32, who had existing stage IV pressure injuries, did not receive consistent care as per the care plan. The facility failed to complete weekly pressure injury assessments and missed multiple wound clinic appointments. R32's care plan required repositioning every hour, but observations indicated that R32 was left sitting in a wheelchair for extended periods without repositioning. Additionally, the facility did not apply the wound vac as ordered, and there were inconsistencies in wound measurements between the facility and the wound clinic, indicating a lack of proper assessment and documentation. The deficiencies in care for both residents were compounded by inadequate communication and documentation. The facility did not notify the wound clinic of changes in R32's wound care, such as the removal of the wound vac, and there was a lack of documentation regarding R151's refusal of care. These failures in care planning, intervention implementation, and communication led to actual harm for the residents, as evidenced by the worsening of their pressure injuries.
Removal Plan
- Completed wound assessments for residents with pressure injuries and skin assessments for all in-house residents.
- Updated care plans with pressure prevention interventions.
- Educated licensed nursing staff on the facility's policy, assessing residents upon admission, implementing pressure injury prevention interventions, implementing treatment orders, documentation, and provider notification.
- Educated nursing and therapy staff on implementing pressure injury prevention interventions.
- Implemented audits to ensure compliance.
Deficiency in Food Safety and Sanitation Documentation
Penalty
Summary
The facility failed to ensure that food was prepared in a clean and sanitary environment, which had the potential to affect over 75% of the 48 residents, as two of the residents received tube feeding. The deficiency was identified during an initial tour with the Dietary Manager, where the surveyor noted missing documentation in the sanitization logs. Specifically, the logs lacked records of parts per million (PPM) for the sanitization solution and sink wash temperatures on multiple dates in August, September, and October 2024. This lack of documentation indicates that staff did not consistently test or record the concentration of the sanitizing solution, as required by the 2022 FDA Food Code. Additionally, the facility did not consistently document refrigerator and freezer temperatures, which is crucial for maintaining food safety. During the same tour, the surveyor observed missing temperature records for cold storage on several dates in October, as well as in August and September 2024. The absence of these records suggests that the facility did not adhere to the FDA Food Code's guidelines for cooling and storing food at safe temperatures. These lapses in documentation and monitoring could compromise the safety and quality of food served to the residents.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman regarding the transfer or discharge of four residents to the hospital. This deficiency was identified through interviews and record reviews conducted by surveyors. The residents involved were hospitalized for various medical conditions, including changes in condition, complications from surgery, gastrointestinal bleeding, and unplanned discharges. Despite these hospitalizations, the facility did not have documentation of the required notices being sent to the Ombudsman. For instance, one resident was hospitalized multiple times for a change in condition, and the Director of Nursing confirmed the absence of notification documentation. Another resident, who had undergone surgery for colon cancer, was transferred to the hospital twice, yet the facility's email to the Ombudsman did not include these transfers. Similarly, a resident with a gastrointestinal bleed and another with unplanned discharges were transferred to the hospital without the Ombudsman being notified. The facility's communication to the Ombudsman only included admissions, discharges, and deaths, omitting hospital transfers.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper personal protective equipment (PPE) usage and inadequate hand hygiene practices. Staff members were observed providing care to residents on enhanced barrier precautions (EBP) and contact precautions without wearing the necessary gowns and gloves. For example, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) entered a resident's room without donning PPE, despite the resident being on contact precautions due to methicillin-susceptible Staphylococcus aureus (MSSA). Similarly, another resident with a gastrostomy tube was assisted with a Hoyer lift by staff who did not wear gowns, contrary to the facility's policy. In addition to PPE violations, the facility's staff demonstrated poor hand hygiene practices during personal care and wound care activities. For instance, two CNAs provided personal care to a resident without changing gloves or performing hand hygiene between tasks, leading to potential cross-contamination. Another RN was observed performing wound care without wearing a gown and failed to turn off the faucet with a paper towel after washing hands, which is against the facility's hand hygiene policy. The facility's Director of Nursing (DON) acknowledged the lapses in infection control practices, indicating that staff were provided education and audited for compliance. However, the observed deficiencies suggest a lack of adherence to the facility's policies and the Centers for Disease Control and Prevention (CDC) guidelines. These failures in infection control practices had the potential to affect several residents, increasing the risk of transmission of communicable diseases and infections.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete and submit a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days after a significant change in condition was identified for a resident. The resident, who was admitted to the facility with diagnoses including cardiomyopathy ischemic, hypertension, and congestive heart failure, was admitted to Hospice services on June 24, 2024. Despite this significant change, the facility did not complete a Significant Change MDS assessment. The most recent MDS assessment on record was a Medicare - 5 day assessment. During an interview, the Director of Nursing confirmed with the MDS Coordinator that the assessment had not been completed. Additionally, the facility did not have a policy in place regarding Significant Change MDS assessments.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for one of the residents reviewed. The resident, who was admitted and later discharged, had multiple diagnoses including orthopedic aftercare, diabetes mellitus type 2, and several other medical conditions. Upon review of the resident's medical record, the surveyor was unable to find evidence of a baseline care plan. During an interview, the Director of Nursing acknowledged that a baseline care plan should have been completed within the required timeframe but was unable to locate the necessary documentation.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their medical and psychosocial needs. One resident, who was prescribed trazodone for insomnia, did not have a sleep hygiene care plan with interventions to promote sleep. Despite being cognitively intact and requiring assistance with activities of daily living, the resident's care plan lacked non-pharmacological interventions to support sleep, as confirmed by the Director of Nursing during an interview. Another resident, also cognitively intact, had a diagnosis of venous insufficiency and was under wound care management. However, the facility did not maintain a comprehensive care plan for skin integrity, as the existing care plan was resolved and removed without being replaced. This oversight was acknowledged by the Director of Nursing when the surveyor inquired about the missing care plan, highlighting a lapse in maintaining ongoing care documentation for the resident's condition.
Failure to Provide Discharge Summary with Recapitulation of Stay
Penalty
Summary
The facility failed to provide a discharge summary that included a recapitulation of stay for a resident who was discharged. The resident, identified as R49, was admitted to the facility with multiple diagnoses, including orthopedic aftercare, diabetes mellitus type 2, and emphysema, among others. R49 was admitted following a C3-C6 laminectomy and planned to discharge home. On the date of discharge, R49 chose to leave the facility before the completion of skilled services. Upon review, the surveyor found that R49's medical record did not contain a recapitulation of stay. During an interview, the Director of Nursing acknowledged the absence of the recapitulation and confirmed it should have been completed.
Failure to Verify Feeding Tube Placement
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding had their feeding tube placement verified according to established protocols, leading to a deficiency. Resident R40, who was admitted with dysphagia following a stroke and esophageal obstruction, required nutrition via a gastrostomy tube. The facility's policy required staff to verify the tube's placement by checking the external markings and gently tugging on the tube before administering feedings or flushes. However, during an observation, a registered nurse (RN) administered a flush without verifying the tube's placement as per the policy. Instead, the RN relied on listening for a 'whoosh' sound, which is not in line with the facility's procedures. The deficiency was identified during a survey when the surveyor observed the RN's actions and questioned the method used to verify the tube's placement. The RN admitted to not checking the tube's markings or measuring its length, which contradicted the facility's policy. The Director of Nursing acknowledged the oversight and indicated that the nursing staff should be aware of the correct procedures for checking feeding tube placement. This incident highlights a lapse in following the facility's established protocols for ensuring the safe administration of enteral feedings.
Improper Insulin Administration Practice
Penalty
Summary
The facility failed to ensure proper procedures were followed for the administration of insulin to a resident, identified as R25. During an observation, a Registered Nurse (RN) was seen using an insulin syringe to draw insulin from a pre-filled insulin pen, which is not recommended according to the facility's policy or external guidelines. The facility's policy on medication administration did not specify whether using an insulin syringe to draw insulin from a pre-filled pen was appropriate. The Institute for Safe Medication Practices and the ASHP guidance document both advise against using insulin pen cartridges as vials due to risks of contamination and dosing errors. The resident, R25, expressed concerns about her blood sugar levels, noting they were more controlled when insulin was administered differently. The Director of Nursing (DON) was unaware of any order allowing this practice and confirmed that the facility's policy did not support drawing insulin from pens. The pharmacist was also unaware of this practice and assumed insulin was being provided in vials as per the order in the Medication Administration Record (MAR). The pharmacist stated that drawing insulin from a pen is not recommended due to the higher risk of error.
Deficiency in Psychotropic Medication Assessment and Monitoring
Penalty
Summary
The facility failed to ensure that a resident prescribed psychotropic medication was comprehensively assessed and had non-pharmacological interventions implemented to determine the adequate indication for the use of the medication. The resident, who was prescribed trazodone for insomnia, did not have a sleep hygiene care plan developed, nor were there any documented non-pharmacological interventions to promote sleep. Additionally, there was no documentation of sleep behavior monitoring over the last 30 days to assess the effectiveness of the medication. The Director of Nursing (DON) confirmed that the sleep assessment conducted in November of the previous year was incomplete, lacking a care plan and interventions. The facility did not conduct regular audits to determine the resident's sleep pattern or the continued need for trazodone. The only sleep study available was from 2019, and the staff's routine checks on the resident's ostomy bag did not include documentation of the resident's sleep status. This lack of comprehensive assessment and monitoring led to the deficiency identified by the surveyor.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during meal times, as observed in the cases of two residents. Resident 24, who has Alzheimer's disease and anemia, was observed being fed by a CNA who stood over her, contrary to the care plan that required assistance with setup and encouragement to eat. Similarly, Resident 16, diagnosed with Parkinson's disease and legal blindness, was fed by the same CNA while standing, despite the care plan indicating the resident was independent after setup and required assistance only as needed. The Director of Nursing acknowledged that staff should be seated when assisting residents with meals, indicating a deviation from the facility's policy on enhancing the dining experience through person-centered care.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure that food was stored in a sanitary manner and appropriately labeled and dated, as observed during a survey. In the Cedar Ridge, Bear Creek, and Deer Trails kitchenettes, various food items were found undated, unlabeled, or expired. These included containers of fruit punch, protein drinks, lemonade, cranberry juice, milk, orange sherbet, dill dip, cranberry almond chicken salad, and rotten cucumbers. Additionally, a pitcher with a sediment ring was found, indicating unsanitary conditions. Dietary Aide (DA)-E acknowledged the disorganization and lack of cleanliness in the Deer Trails unit refrigerator and confirmed that kitchen staff were responsible for dating and cleaning items. Dietary Director (DD)-D confirmed that unit refrigerators could be used for resident food, which should be labeled, dated, and kept for no more than seven days. Furthermore, the surveyor observed two thawed and undated Sysco Imperial vanilla shakes on a medication cart in the Cedar Ridge unit. The instructions on the shakes indicated they should be stored frozen, thawed under refrigeration, and used within 14 days of thawing. LPN-J confirmed that the shakes were not dated when removed from the freezer. DD-D stated that supplements are typically dated 10 days from removal from the freezer and delivered to units by dietary staff, although sometimes nurses might remove them without dating. This lack of proper labeling and dating of food items and supplements posed a potential risk to residents' safety.
Deficiencies in ADL Assistance and Call Light Response
Penalty
Summary
The facility failed to provide necessary and timely assistance with activities of daily living (ADLs) for three residents. One resident, who was dependent on staff for bathing, did not receive showers as scheduled. The resident was supposed to receive a shower every Tuesday, but there were significant gaps between the showers provided, with intervals of 11 and 14 days without a shower. The Director of Nursing confirmed that the documentation indicated missed showers, which should have been provided weekly. Another resident, who had a medical condition requiring weekly diabetic nail care, did not receive consistent nail care. The resident's care plan did not include an intervention for nail care, and the facility failed to document nail care consistently. During an interview, a registered nurse was unable to confirm when the resident's nails were last cut, and the resident's nails were observed to be long and untrimmed. A third resident experienced a delay in response to their call light, which was activated for approximately 26 minutes before staff responded. The resident, who had been admitted the previous day, wanted to get out of bed but was left waiting due to staff being occupied with other duties. The facility's policy did not specify an appropriate call light response time, but the delay was acknowledged as excessive by the Regional Consultant.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent and manage pressure injuries for two residents, R1 and R7. For R1, the facility did not ensure appropriate hand hygiene during wound care, and care-planned pressure-relieving measures were not consistently implemented. R1's medical record lacked proper wound assessment documentation and timely response to newly opened areas. R1 was admitted with a laceration, a blister, and red, spongy heels, and later developed multiple stage 3 and stage 4 pressure injuries, which were not present upon admission. The facility's failure to conduct thorough assessments and consult the wound MD sooner contributed to the deterioration of R1's wounds. During an observation, RN-F did not change gloves or perform hand hygiene between dressing changes and when moving from soiled to clean parts of the dressing change. RN-F also failed to perform hand hygiene immediately after removing gloves and PPE. Additionally, R1's heel lift boots were not in place as required by the care plan. The Director of Nursing and Assistant Director of Nursing acknowledged these lapses in protocol and documentation, which hindered the facility's ability to provide effective wound care and prevent further deterioration of R1's pressure injuries. For R7, the facility did not consistently implement the care plan intervention to float/elevate heels and use heel lift boots. R7 had a history of a pressure injury on the left heel, and the care plan included interventions to prevent further injury. However, during an observation, R7's heels were in direct contact with the mattress, and R7 was not wearing heel boots or poseys. R7 expressed discomfort with the boots, stating they scraped the skin, which led to non-compliance with the intervention. The facility's failure to address R7's concerns and ensure consistent implementation of pressure-relieving measures contributed to the deficiency in care.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide necessary respiratory care for two residents, R3 and R5, as identified during a survey. R3 was admitted with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and obstructive sleep apnea. Despite having a physician's order for BiPAP therapy, R3 was provided with CPAP therapy without a physician's order, and the facility did not obtain the required BiPAP equipment. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that R3 received CPAP therapy without an order and that the care plan did not reflect the use of CPAP therapy. Additionally, the Respiratory Therapy Company had no record of the facility requesting BiPAP equipment for R3. R5, who was admitted with a diagnosis of obstructive sleep apnea, had a physician's order for CPAP therapy. However, R5's care plan did not address the need for or use of CPAP therapy. Interviews with the Assistant Director of Nursing and Nursing Home Administrator confirmed that a care plan should have been in place to address R5's CPAP therapy needs. The lack of a care plan for R5 and the inappropriate use of CPAP therapy for R3 without a physician's order highlight deficiencies in the facility's respiratory care management.
Medication Administration Error Due to Transcription Mistake
Penalty
Summary
The facility did not ensure accurate administration of medication for one resident (R4) due to a transcription error. R4, who had intact cognition and was responsible for their healthcare decisions, received an incorrect medication (triple antibiotic ointment) instead of the prescribed triamcinolone ointment. This error occurred after R4 returned from a dermatology appointment with a handwritten order for triamcinolone ointment. The error was identified when R4's medical record and treatment administration record (TAR) were reviewed, revealing that R4 received the incorrect medication from 2/7/24 to 2/20/24 and missed several doses of the correct medication from 2/27/24 to 3/6/24. Additionally, R4 refused several doses of the triamcinolone ointment due to a reaction, which was not properly documented or communicated to the dermatology clinic in a timely manner. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the transcription error and the administration of the incorrect medication. The LPN indicated that they had difficulty contacting the dermatology clinic to discontinue the triamcinolone ointment after R4 had a reaction. The DON verified that the facility did not have an order to administer the triple antibiotic ointment and acknowledged the need for staff to clarify unclear orders rather than guessing. The facility also lacked documented staff education regarding medication and transcription errors following the incident.
Latest citations in Wisconsin
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident was admitted to hospice, which the facility’s DON identified as a significant change in condition requiring a Significant Change in Status Assessment (SCSA) MDS to be completed within 14 days per the RAI User Manual and facility policy. The last MDS for this resident had been completed earlier, and although an SCSA was started after the hospice admission, it was never completed or submitted. The resident later died, and the DON acknowledged that the significant change MDS was not completed within the required timeframe.
A resident with obesity, weakness, and type 2 DM with polyneuropathy, who had no cognitive impairment and required a sit-to-stand mechanical lift with two-person assist per the care plan, experienced a fall during a transfer when a CNA performed the lift alone. The CNA unhooked one side of the sling, had difficulty reaching the other side, unlocked the lift while the resident was partially on the bed with feet on the device and holding a trapeze, and the lift moved forward as the resident pushed with their legs, causing the resident to slide to the floor. Staff interviews confirmed that transfer requirements are obtained from the care plan/Kardex, that mechanical lifts may require two staff depending on the plan, and that this resident specifically required two-person assistance, but only one CNA was present at the time of the fall.
The facility failed to maintain required RN coverage and a full-time DON, resulting in no RN on duty for multiple days and no documented RN supervision of nursing staff. In this context, LPNs completed admission and readmission assessments for several residents with complex conditions such as diabetes, COPD, CHF, sepsis, ESRD, and osteomyelitis, and administered IV antibiotics, including via PICC lines, sometimes without appropriate IV certification. CMA/MTs independently assessed pain, administered PRN oxycodone, and injected insulin for a resident with diabetes and pressure ulcers, all without an RN employed to provide direct supervision. Leadership acknowledged reliance on LPNs and CMAs for these functions and on off-site or sister-facility DONs for support, but could not provide documentation of on-site RN coverage, leading surveyors to cite an immediate jeopardy deficiency.
A resident with COPD, emphysema, and leukemia, who was cognitively intact, reported shortness of breath and wheezing and received a PRN nebulizer treatment documented as effective, but no vital signs or comprehensive respiratory assessment were completed. Later, the resident told an LPN that she might need to go to the hospital due to ongoing shortness of breath; the LPN acknowledged this but did not immediately assess the resident, citing that the resident often complained and did not appear in dire need. The resident and her family member reported that she clearly requested to go to the hospital and that staff did not act, leading the family member to call 911. EMS transferred the resident to the hospital, where she was found to be hypoxic and was diagnosed with acute hypoxic respiratory failure, chronic PE, and bronchiectasis with acute lower respiratory infection.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
The facility failed to provide enough qualified nursing staff and allowed improper delegation of nursing and medication tasks. On an evening shift, only three CNAs (one for a partial shift) were assigned to 34 residents, despite the facility’s own staffing plan calling for higher CNA coverage. A resident with multiple serious conditions, dependent for transfers and incontinent, reported waiting over three hours for toileting assistance and described routinely long call-light response times, while a family member reported chronic delays in staff response. A CMA/MT had been independently assessing pain and administering PRN oxycodone, including using a nonverbal pain scale, even though facility policy and state guidance restrict unlicensed staff from performing assessments or making PRN decisions. Multiple residents’ admission and readmission assessments and baseline care plans were completed and signed by LPNs without RN assessment, and LPNs were administering IV ertapenem via PICC lines without documented IV training or formal RN delegation, contrary to facility policy and Wisconsin scope-of-practice standards.
Surveyors found that the facility failed to follow its own food safety and sanitation policies, resulting in expired and improperly labeled food items stored in the walk-in cooler and freezer, including multiple juices and fish past their use-by or manufacturer expiration dates, as well as a torn-open package of hot dog buns exposed to air. They also observed cobwebs, dead insects, and accumulated dust and debris on the wall behind shelving where clean dishes were stored, with nearby window air-conditioning units that could blow contaminants onto the dishes. A dietary aide acknowledged that dietary staff should be monitoring expiration dates, and leadership later confirmed the expectation that expired items and unsanitary conditions should not be present, while 34 residents were placed at risk of foodborne illness.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Complete Timely Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe after a resident experienced a significant change in condition. Facility policy on comprehensive assessments, last revised on an unspecified date, states that comprehensive assessments are to be conducted according to the criteria and timeframes in the Resident Assessment Instrument (RAI) User Manual, which requires that an SCSA be completed by the end of the 14th calendar day following determination of a significant change. The Director of Nursing (DON) stated that MDS assessments are completed on admission, annually, quarterly, with a significant change, and as needed, and that a significant change includes a decline or improvement in two or more areas of care or when a resident is admitted to or removed from hospice, with a completion timeframe of 14 or 15 days after recognizing the change. Surveyor review of the resident’s electronic health record showed that the last completed MDS assessment was done on a prior date, and the resident was later admitted to hospice, which the DON identified as a significant change requiring an SCSA. An SCSA was initiated after the hospice admission but was left incomplete and never submitted. The resident subsequently expired, and the DON acknowledged during interview that the significant change MDS had not been completed and was past the 14-day requirement.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and adherence to the care plan for a resident requiring assistance with mechanical lift transfers. The facility’s own policies on falls and person-centered care planning require implementation of resident-specific fall prevention measures and provision of services as outlined in the care plan. For this resident, the comprehensive care plan identified self-care deficits related to type 2 diabetes and morbid obesity and specified that all transfers were to be completed using a sit-to-stand mechanical lift with the assistance of two staff. The resident, who had diagnoses including abnormal posture, weakness, type 2 diabetes with polyneuropathy, and morbid obesity, and who had no cognitive impairment per a BIMS score of 13/15, experienced a fall during a transfer. Progress notes document that a CNA was performing a sit-to-stand mechanical lift transfer to bed with only one staff member present, despite the care plan requirement for two-person assistance. During the transfer, the CNA had unhooked one side of the sling and was attempting to unhook the other side, had difficulty reaching, and then unlocked the sit-to-stand lift while the resident was partially on the bed, with feet on the lift and holding the bed trapeze. Because the resident was pushing with their legs, the lift moved forward and the resident slowly slid to the floor. Interviews confirmed that staff were aware that mechanical lifts, including sit-to-stand devices, may require two staff depending on the care plan, and that this resident specifically required two-person assistance for transfers. The resident reported that only one CNA was present at the time of the fall and that usually two staff assist due to the resident’s size. Nursing and CNA staff described that they rely on the care plan or Kardex in the computer to determine transfer needs and acknowledged that sit-to-stand lifts can require one or two staff based on the resident’s plan of care. The DON acknowledged that the CNA involved was working alone during the transfer when the fall occurred and was not following the resident’s care plan.
Lack of RN Coverage and Oversight Leading to Out-of-Scope Nursing and Medication Practices
Penalty
Summary
The deficiency involves the facility’s failure to employ a full-time RN designated as the DON and to ensure RN services were provided at least eight consecutive hours a day, seven days a week, as required by regulation and by the facility’s own nursing services policy. Payroll-Based Journal staffing data for the first quarter of 2026 showed a one-star staffing rating and multiple days with no RN hours. Review of daily staffing schedules for several consecutive days in March showed no RN scheduled on any of those dates, indicating there was no RN assigned to supervise nursing staff or oversee resident care. The Administrator confirmed that the DON, who had been the only full-time RN, resigned and her last day was mid-March, and the ADON confirmed that since that resignation there had been no RN employed by the facility and that even when a DON was employed, most weekends did not have RN coverage. In the absence of consistent RN presence and oversight, LPNs were performing admission and readmission nursing assessments and administering IV medications, and CMA/MTs were performing pain assessments, administering PRN pain medications, and administering insulin, all of which were outside their scope of practice as described in the report. Multiple residents’ records showed admission data collection and baseline care plan tools completed and signed by LPNs rather than an RN. For example, one resident admitted with diabetes type 2, osteomyelitis of vertebra, and orthopedic aftercare had a 72-hour admission/re-admission assessment documented by an LPN. Another resident admitted with COPD and traumatic ischemia of muscle had admission data collection and baseline care plan tools completed and signed by an LPN, with a late-entry health status note by a sister-facility DON added seven days after admission. Additional residents admitted with chronic congestive heart failure, sepsis, diabetes type 2, congestive heart failure, and ESRD also had admission data collection notes completed by LPNs. The report further documents that LPNs administered IV medications, including through PICC lines, without RN oversight, and in at least one case outside the LPN’s own training and certification. One resident with an order for IV ertapenem had doses administered on three consecutive days by an LPN and the ADON, who is also an LPN. The ADON stated that most LPNs had been trained to administer IV medications, but identified two LPNs who were not certified, while the former DON stated she believed those LPNs were certified and had allowed them to administer IV medications after observing them. CMA/MTs were documented as completing pain assessments and administering PRN oxycodone and insulin injections without an RN employed to provide direct supervision. One resident with diabetes type 2, bilateral stage II heel pressure ulcers, chronic pulmonary embolism, and vertebral osteomyelitis had multiple pain assessments and PRN oxycodone doses documented by a CMA/MT, as well as several insulin doses administered by the same CMA/MT. Interviews with the RDO and Medical Director confirmed that RN coverage was expected to be provided by DONs from sister facilities, but there was no documentation of their presence in the building, and the Medical Director emphasized that RNs are responsible for assessments, IVs, and staff supervision to ensure practice within scope. These combined actions and inactions led surveyors to identify immediate jeopardy beginning in mid-March.
Removal Plan
- Employ a full-time interim DON
- Provide staff education on notification of changes in condition
- Assess nurses' IV competency
- Employ an agency RN to ensure RN coverage on Saturdays and Sundays
- Reassess all residents with IVs, pressure injuries, and new admissions
- Reassess all residents with a documented change in condition
Failure to Assess Resident’s Respiratory Change in Condition and Request for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond appropriately to a resident-reported change in condition related to respiratory symptoms. The resident had significant medical diagnoses including COPD, panlobular emphysema, osteomyelitis of the lumbar vertebra, and chronic myeloid leukemia. A recent MDS showed the resident was cognitively intact with a BIMS score of 15 and used a wheelchair for mobility. The care plan also identified a focus on the resident and spouse making inappropriate EMS 911 calls when no true emergency existed, with interventions focused on educating them about appropriate EMS use. On the day of the incident, the resident reported shortness of breath and wheezing and received a PRN nebulizer treatment of Ipratropium-Albuterol, which was documented as effective. However, the LPN did not collect additional assessment data or notify an RN of the resident’s complaint of shortness of breath. No comprehensive respiratory assessment or vital signs were obtained at that time despite the resident’s symptoms. Later that same day, the resident told the LPN that she "may need to go to the hospital" and reported feeling short of breath. The LPN acknowledged that the resident made this statement but did not immediately assess the resident, stating she believed the resident was not in dire need and that the resident often complained of various ailments. According to the resident’s account, she specifically told the LPN that she needed to go to the hospital, was wheezing a lot, and tried to stay calm while waiting about an hour without staff action, after which she called her husband. The husband reported that the resident was crying, calling out in the hallway, and that he called 911 because staff were not doing anything. The facility’s grievance file and staff statements documented that the LPN was aware the resident said she "may need to go to the hospital" but did not complete an assessment before EMS arrived. The resident was transferred to the hospital, where she was found to have hypoxia with low oxygen saturation and was diagnosed with acute hypoxic respiratory failure, chronic pulmonary emboli without acute cor pulmonale, and bronchiectasis with acute lower respiratory infection. The Medical Director later stated her expectation that when a resident states they want to go to the hospital, staff should conduct an assessment, obtain vital signs, and report to the provider.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
Inadequate Staffing and Improper Delegation of Nursing and Medication Tasks
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient and appropriately qualified nursing staff to meet residents’ needs, and failure to ensure that LPNs and CMAs/MTs practiced within their legal scope and professional standards. The facility’s own facility assessment called for a CNA-to-resident ratio of one CNA for ten to sixteen residents on the evening shift, yet on the evening of survey entry there were only three CNAs for 34 residents, with one CNA scheduled for only a partial shift. Interviews and documentation, including a police body-worn camera narrative, showed that staff and leadership acknowledged difficulty providing needed care due to lack of staffing. The Nursing Home Administrator told police that one resident needed constant care that was difficult to provide because of staffing shortages, and an LPN stated she felt residents needed more attention than staff could provide. One resident with osteomyelitis of the lumbar vertebra, COPD, emphysema, and chronic myeloid leukemia, who was wheelchair-bound, dependent for transfers, and frequently incontinent of bowel, reported waiting over three hours for assistance after a bowel movement, prompting a call to local police. This resident later told the surveyor that call lights usually took 30–45 minutes to be answered and that care was timelier while surveyors were present. A family member reported that it took staff “forever” to respond to this resident’s needs and that he had complained to the ADON about response times. These accounts, combined with staffing records, demonstrated that the facility did not have enough staff on duty to meet residents’ immediate care needs. The facility also failed to ensure that CMAs/MTs and LPNs practiced within their scope and under appropriate RN oversight. A CMA/MT had been independently assessing residents’ pain and administering PRN oxycodone, including documenting pre- and post-administration pain levels, despite state guidance that assessments cannot be delegated to unlicensed personnel and facility policy stating that CMAs/MTs are not to assess pain or administer PRN medications without an RN’s assessment. The CMA/MT reported using both verbal reports and a nonverbal pain scale and believed this was within her scope, while the VPCO and FDON later stated it was not. Additionally, multiple admission and readmission nursing assessments and baseline care plan tools for several residents were completed and signed by LPNs without evidence of RN assessment, even though state standards limit LPNs to data collection and require RNs to complete resident assessments. The FDON and ADON acknowledged that, in the absence of an RN DON and because most admissions occurred on evenings, LPNs had been completing all initial nursing assessments for years. Further, the facility did not ensure that LPNs performing IV therapy had the required additional training and RN delegation as outlined in facility policy and state guidance. One resident with an order for IV ertapenem via PICC line received this medication on multiple days from LPNs, including an LPN whose personnel file contained no documentation of IV therapy training. The ADON confirmed that this LPN was not certified to administer IV/PICC medications, while the LPN stated she had been hanging IV medications via PICC lines since hire, without formal facility training, and was sometimes the only nurse available to administer PICC medications, with the other staff person being a CMA/MT. The FDON stated she supervised licensed staff and had observed LPNs administering IV medications without concerns, but there was no evidence of the documented training and competency validation required by facility policy for delegation of IV tasks to LPNs. Collectively, these findings showed that the facility did not maintain adequate RN presence, did not follow its own delegation and competency policies, and allowed LPNs and CMAs/MTs to perform assessments and IV tasks beyond their scope, affecting all residents in the facility.
Expired Food and Unsanitary Kitchen Conditions in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to follow its own food safety and sanitation policies. The facility’s policies required that all local, state, and federal standards be followed, that food be protected from contamination, and that perishable foods be used prior to their use-by or expiration dates, with out-of-date foods discarded. During an observation of the kitchen’s walk-in cooler, surveyors found multiple juice containers labeled by the facility with use-by dates that had already passed, including cranberry juice, orange juice, and apple juice. They also found a container of concentrated lemon juice with a manufacturer’s expiration date that had already passed, despite the facility having applied a later “use by” date that extended beyond the manufacturer’s expiration. Further observations in the kitchen’s walk-in freezer revealed a torn-open package of hot dog buns with several buns exposed to air and an opened box of fish with a manufacturer’s expiration date that had already passed. Additional inspection of the kitchen area showed multiple cobwebs and dead insects on the wall behind portable shelving where clean dishes were stored, along with a buildup of black and gray dust and debris. Two window unit air conditioners were located next to this shelving, with the potential to blow debris and pests onto the clean dishes if turned on. A dietary aide acknowledged these conditions during the survey, stating that all dietary staff should be checking use-by and expiration dates. The Regional Director of Operations later stated it was her expectation that there would be no items beyond use-by or expiration dates and no dust or dead bugs in the kitchen. These failures placed all 34 residents at risk of foodborne illnesses.
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