Citations in Wisconsin
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Wisconsin.
Statistics for Wisconsin (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Wisconsin
Surveyors identified multiple deficiencies in food service sanitation, including staff not using proper hair restraints, unclean kitchen equipment, personal beverages on food prep counters, improper storage of food under freezer drips, and opened food items without required dating. These failures affected all residents, as they occurred in areas where food for the entire facility is prepared and stored.
The facility did not have an infection prevention and control program in place, as observed and documented by surveyors.
A resident with a history of chronic kidney disease, diabetes, and urge incontinence was treated for an acute urinary tract infection with ciprofloxacin without a culture and sensitivity test to confirm the antibiotic's effectiveness. Facility policy requires such testing and review by the Infection Preventionist, but documentation was lacking, and leadership confirmed the omission during the survey.
A resident with multiple chronic conditions indicated a preference to receive the RSV vaccine by signing the appropriate consent form, but the vaccine was not administered. The Infection Preventionist confirmed the vaccine was not given and stated it would have required ordering from the pharmacy, acknowledging the resident should have received it as requested.
Two residents did not have current advance directives or documentation of advance care planning in their records, and there was no evidence that they were offered assistance or that their preferences were documented, despite facility policy requiring this. The Social Services Director confirmed the absence of required documentation and follow-up.
Two residents voiced grievances regarding lack of assistance with mobility and dissatisfaction with wound care, but the facility did not follow its grievance policy to investigate, document, or resolve these concerns. Staff acknowledged the complaints but failed to initiate the required grievance process or communicate outcomes to the residents.
A resident with a history of stroke, hemiplegia, and moderate cognitive impairment was found with unexplained swelling and bruising, later requiring hospitalization for a hematoma and pneumothorax. Facility staff did not conduct a risk management investigation or report the injury of unknown origin to the NHA or State Agency, contrary to policy and regulatory requirements.
Two residents did not receive care planned interventions to prevent accidents and falls. One resident, requiring two-person assist and proper use of an EZ stand lift, was transferred by a CNA without fastening the safety strap and without a second staff member, resulting in a fall to the floor. Another resident, assessed as a fall risk and requiring gripper socks at all times, was observed wearing regular socks, and staff were unaware of his care plan requirements. Facility staff did not follow care plans or manufacturer instructions, leading to deficiencies in accident prevention.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment lacked proper hazard controls and sufficient monitoring, increasing the risk of accidents for residents.
A resident with moderate cognitive impairment and a history of wandering left the facility without staff authorization after independently arranging transportation. Although the care plan noted the guardian's permission for the resident to leave for smoking, no new interventions or monitoring were added following the incident, despite facility policy requiring updates to care provision after such events.
Failure to Maintain Sanitary Food Service Environment and Practices
Penalty
Summary
Surveyors observed multiple failures in maintaining a safe and sanitary environment in the facility's food service operations. Staff in the food preparation area were seen without proper hair restraints, including one staff member wearing a personal baseball cap and another with a stocking cap not designated for kitchen use. The facility's policy requires clean, designated hair restraints, but staff were unclear on laundering frequency and whether hats were used outside the facility. Additionally, a mixer was found stored with visible food residue inside, indicating it had not been cleaned before storage. Staff were also observed with personal beverages on food preparation counters, contrary to facility policy prohibiting eating and drinking in these areas. Further deficiencies included improper food storage practices. Surveyors found frozen drips on the ceiling of the walk-in freezer, with opened and unsealed boxes of vegetables stored underneath, resulting in ice buildup on and inside the boxes. Opened containers of juice in the juice machine were undated, and staff were unable to confirm when they had been opened. Facility policy requires all opened food and beverages to be labeled with an open or use-by date, but this was not followed. These observations affected all 47 residents in the facility, as the issues were present in areas where food for all residents is prepared and stored.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Follow Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to follow its own standards of practice for antibiotic stewardship by not ensuring that a culture and sensitivity test was performed before prescribing antibiotics for a resident diagnosed with an acute urinary tract infection. The resident, who had a medical history including chronic kidney disease, Type 2 diabetes mellitus, and urge incontinence, experienced symptoms such as pain, itching, and burning in the vaginal area. After being seen in the emergency department, the resident was diagnosed with a urinary tract infection and prescribed ciprofloxacin without evidence of susceptibility testing to confirm the appropriateness of the antibiotic. Facility policy requires that antibiotic use be based on clinical standards, including evaluation of symptoms and, when necessary, obtaining further documentation to support the treatment plan. The Infection Preventionist or designee is responsible for reviewing antibiotic orders, which includes ensuring the necessity and appropriateness of the treatment. During the survey, the Vice President of Clinical Operations confirmed that there was no culture and sensitivity test documented in the resident's electronic health record, acknowledging that such testing should have been completed to ensure the correct antibiotic was prescribed.
Failure to Administer RSV Vaccine per Resident Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to participate in and make informed decisions about her treatment. The resident, who had a medical history including multiple sclerosis, pneumonitis, and a personal history of Covid-19, was offered the Respiratory Syncytial Virus (RSV) vaccine. She indicated her preference to receive the vaccine by checking 'Yes' and signing the Acknowledgement of Receipt of Vaccine Information Sheet. Despite this documented preference, there was no evidence in her electronic health record that the RSV vaccine was administered. During an interview, the facility's Infection Preventionist confirmed that the resident did not receive the RSV vaccine and explained that the facility would have needed to contact the pharmacy to obtain it, as it was not stocked in-house. The Infection Preventionist also acknowledged that the resident should have received the vaccine according to her expressed wishes. This failure to provide the vaccine as requested was not in accordance with the facility's policies on resident rights and self-determination.
Failure to Document and Facilitate Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' rights to request, refuse, and/or discontinue treatment and to formulate an advance directive were honored, as required by facility policy. For both residents, their charts did not contain current copies of their advance directives or documentation of advanced care planning beyond code status. During record reviews, surveyors were unable to locate copies of the residents' advance directives or Power of Attorney for Health Care (POAHC) in the electronic medical records. Interviews with the Social Services Director confirmed that there was no documentation on file for either resident regarding their advance directives or evidence that assistance was offered or preferences were documented. In one case, documentation indicated that a resident was interested in completing advance directive documents, but there was no evidence that assistance was provided or that this interest was followed up on. The Social Services Director acknowledged that documentation should have been present to show that residents were offered assistance in completing advance directives and that their preferences were recorded. The lack of documentation and follow-up regarding advance care planning for these residents constituted a failure to comply with the facility's own policy and federal requirements.
Failure to Investigate and Resolve Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not follow its own grievance policy for two residents. The policy requires prompt investigation, documentation, and resolution of grievances, overseen by a designated Grievance Official. In both cases, the facility did not document a thorough investigation or resolve the grievances as outlined in their procedures. One resident, who had moderate cognitive impairment and multiple mobility-related diagnoses, expressed concerns about not receiving assistance when moving from the dining room to his room. Progress notes indicated that the resident was upset about not being helped and voiced his intention to report the issue. Staff interviews revealed that the concern was not reported as a grievance, and the required documentation and investigation were not completed. The staff acknowledged that the resident frequently expressed such concerns, but no formal grievance process was initiated in response to his repeated complaints. Another resident with a history of diabetic foot ulcers voiced a grievance about wound care, specifically not wanting a particular nurse practitioner to debride her wound due to increased pain. The resident reported her concerns to both the Nursing Home Administrator and a nurse. Although an administrative assistant recognized the concern as a grievance and reported it to the administrator, no grievance form was completed and the facility did not follow up according to its policy. In both cases, the facility did not adhere to its established grievance procedures, failing to ensure prompt investigation, documentation, and communication with the residents involved.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving injuries of unknown origin were reported immediately to the administrator and the State Agency, as required by both facility policy and state law. A resident with a history of cerebral infarction, hemiplegia, difficulty walking, and moderate cognitive impairment was found to have swelling on the right hip and dark purple bruising on the right shoulder and arm. The origin of these injuries was unknown, and the resident was subsequently hospitalized with a hematoma and pneumothorax requiring a chest tube. Despite the facility's policy mandating immediate reporting and investigation of such injuries, there was no documentation of a risk management investigation or notification to the Nursing Home Administrator or State Agency. Interviews with facility staff, including a Registered Nurse/Nurse Manager and the Director of Nursing, confirmed that the expected procedure would have included an assessment, provider notification, investigation, and documentation in risk management. Both staff members acknowledged that this process did not occur for the resident in question. The Nursing Home Administrator also confirmed that the injuries should have been classified as of unknown origin and reported accordingly, but this was not done.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents, as evidenced by two residents who did not have their care planned interventions implemented. One resident, who was assessed and care planned for two-person assistance with an EZ stand lift for transfers, was transferred by a CNA who did not follow the manufacturer’s instructions. The safety strap on the harness was not fastened around the resident’s waist, and the transfer was attempted with only one staff member present. During the transfer, the resident began to slide through the straps and was lowered to the floor, resulting in a change in plane and reported shoulder pain. Multiple staff interviews confirmed that the safety strap was not used as required, and that the resident was not transferred according to her care plan, which specified two-person assistance. Another resident, who had a history of repeated falls and was assessed as a fall risk, was observed without his care planned fall prevention intervention in place. The resident’s care plan and Kardex specified that he should wear gripper socks at all times and not wear shoes due to a wound on his toe. However, the resident was observed in the dining room wearing regular socks, and a CNA admitted to attempting to put shoes on the resident, contrary to the care plan. The resident confirmed that his shoes caused a wound on his toe, and the CNA only provided gripper socks after the surveyor’s intervention. Staff interviews revealed a lack of awareness regarding the resident’s fall risk status and the required interventions. Facility policies required that residents be handled and transferred safely according to their individual care plans and that mechanical lifts be used according to manufacturer instructions. The policies also mandated that fall prevention interventions be implemented and monitored for effectiveness. In both cases, staff failed to follow established care plans and manufacturer guidelines, resulting in residents not receiving the necessary supervision and interventions to prevent accidents and falls.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of appropriate hazard controls and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update a resident's care plan with new interventions or monitoring following an incident of unauthorized elopement. The resident, who was admitted under guardianship with diagnoses including benign neoplasm of meninges and mild cognitive impairment, had a BIMS score of 7, indicating moderate cognitive impairment, and a documented history of wandering and attempted elopement. The resident's care plan allowed for leaving the premises to smoke, as permitted by the guardian, but did not include specific interventions to address the risk of elopement despite the resident's known behaviors and history. On a specific date, the resident independently arranged for transportation and left the facility without staff authorization to attend an appointment that had been cancelled by the guardian. The facility's Director of Nursing confirmed that, although the guardian refused the use of a wander guard and Adult Protective Services were notified, no new interventions or monitoring were added to the care plan to prevent recurrence of such incidents. This lack of updated care planning was not in accordance with facility policy, which requires defining how care provision will be changed or improved to protect residents after such events.
Some of the Latest Corrective Actions taken by Facilities in Wisconsin
- Educated all nursing staff on recognizing resident changes of condition and immediate reporting protocols (J - F0684 - WI)
- Trained staff to use the STOP and WATCH tool to identify changes such as mental status, intake/output, pain, swelling, or skin color (J - F0684 - WI)
- Educated nurses on completing comprehensive head-to-toe assessments with prompt physician notification and thorough documentation (J - F0684 - WI)
- Trained CNAs to accurately record meal fluid and food intake for every resident each shift and document in the chart (J - F0684 - WI)
- Instructed staff on using an intake-tracking spreadsheet and on immediate nurse notification when amounts fall below baseline (J - F0684 - WI)
- Implemented a 24-hour board binder to capture and communicate changes of condition during shift hand-off and daily stand-up (J - F0684 - WI)
- Established a facility process for ongoing monitoring of fluid intake and output with defined MD/NP notification triggers (J - F0684 - WI)
- Implemented a standardized system for reporting resident condition changes to the incoming shift (J - F0684 - WI)
- Initiated DON-led audits of charting, 24-hour reports, intake/output records, and change-of-condition documentation to verify compliance (J - F0684 - WI)
- Directed QAPI committee review of all education, audits, and corrective actions to guide continuous improvement (J - F0684 - WI)
Failure to Recognize and Respond to Change of Condition and Inadequate Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents who experienced changes in condition. For one resident with a history of Alzheimer’s disease, kidney disease, and an indwelling Foley catheter, multiple CNAs observed and reported significant changes including increased lethargy, decreased intake, and changes in urine color and output. Despite these reports, nursing staff did not complete a nursing assessment, did not monitor the resident’s condition, and did not notify the provider of the changes. Documentation of intake and output was inconsistent and incomplete, with staff using non-quantitative symbols instead of actual measurements, making it impossible to determine the resident’s fluid status. The resident’s condition deteriorated over several days, culminating in hospitalization for severe sepsis, bacteremia, and UTI, and ultimately resulted in death. Another resident was subjected to a straight catheterization by an LPN to obtain a urine sample without a physician’s order, which is not permitted by professional standards or facility policy. The resident reported pain and discomfort from the procedure, which was attempted multiple times, including one attempt that resulted in a contaminated sample. Additionally, this resident had multiple wounds that were not consistently assessed or measured, and there was no documentation of an admission skin assessment or classification of the wounds. Physician orders for wound care were not consistently followed, and wound documentation was incomplete and lacked necessary details such as tunneling and depth. Interviews with staff and review of facility documentation revealed a lack of clear responsibility for monitoring intake and output, inconsistent documentation practices, and failures to notify providers of significant changes in residents’ conditions. The facility’s own policies required immediate notification of changes in condition and adherence to the nursing process, but these were not followed. These failures resulted in immediate jeopardy for one resident and demonstrated a pattern of deficient practice in the recognition, assessment, and management of changes in condition and wound care.
Removal Plan
- Educate all nursing staff, including agency, on recognition of change of condition and immediate reporting to the nurse. The nurse will perform a head to toe assessment and notify the PCP of findings.
- Educate staff on recognizing a change of condition, including changes in mental status, intake or output, urine color, communication, pain, swelling, weakness, and skin color. Use the stop and watch warning tool.
- Educate staff to report possible change of condition to the nurse immediately. The nurse will do a full assessment, call the MD, follow MD directions, document the change, notify the POA/MCO, continue monitoring, and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Educate nurses on completing a head to toe assessment, including vitals, pain, GI, respiratory, cardiac, GU symptoms, and immediate MD notification. Continue monitoring and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Train staff on properly recording fluid intake and food percentage for each resident on each shift. CNA assigned to the dining room will record all intakes and ensure residents eating in rooms are recorded. CNA is responsible for charting this information in the resident’s chart.
- Educate staff on recording intakes using the spreadsheet for each meal, properly documenting in the resident’s chart, noting if the amount is off baseline, and immediately reporting to the nurse.
- Educate staff to report immediately to the nurse if the resident’s intake or output has decreased.
- Educate staff on the 24-hour board binder and proper recording of change of condition to be reviewed during report off.
- Sweep the building for any changes in condition.
- Review policy related to changes of condition and notification of changes.
- Implement 24-hour board binder for monitoring and review during stand up.
- Implement process for monitoring fluid intake and output and when to notify MD/NP.
- Review head to toe and system-specific assessment for intake and output.
- Implement system to report off resident change of condition to next shift.
- The DON or designee will conduct audits of charting for change of condition and documentation.
- The DON or designee will conduct audits of the 24-hour report for properly completed and documented assessments and MD notification.
- The DON or designee will conduct audits to ensure changes of condition are recognized, assessments completed, and MD notification.
- The DON or designee will conduct audits of intake sheets and proper documentation in charts.
- The DON or designee will conduct audits of output documentation and proper reporting of inadequate output.
- The DON or designee will conduct audits of the intake sheet and proper documentation and reporting of decreased intake.
- The DON or designee will conduct audits on proper reporting of change of condition to the next shift.
- Review all facility actions, education, and audits at QAPI.
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