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
The facility failed to provide adequate supervision and accident prevention for several residents, including incomplete care planning, inadequate fall investigations, and insufficient smoking safety management. A resident with vertigo and cognitive impairment, assessed as high fall risk and recommended to use a 2WW with supervision, was repeatedly observed walking in hallways without a walker, while the care plan was not updated to clearly reflect current ADL status and supervision needs, and staff allowed ambulation based on how the resident "felt." Another resident who smoked had only sporadic smoking assessments, and neither assessments nor the care plan specified whether smoking should be supervised or whether the resident or staff should hold smoking materials, even though staff reported the resident smoked alone and kept personal smoking supplies. Two additional residents at high risk for falls experienced unwitnessed falls, one with facial bruising and one found on the floor despite being nonverbal and without bed mobility, and in both cases the facility’s fall investigations lacked clear timelines, detailed staff statements, identification of environmental or physiological contributors, root cause analysis, or documentation of what fall-prevention measures were in place at the time of the incidents.
The facility failed to report an alleged incident of abuse to the State Agency within the required 2-hour timeframe. A resident with PTSD and intact cognition told an LPN that a CNA had grabbed the resident’s arm and that the resident felt the CNA’s nails on the skin. The LPN promptly informed the NHA and DON and, per the NHA’s direction, obtained a resident statement and performed a skin check. The NHA acknowledged receiving a text from the LPN about a resident reporting abuse late that evening but did not submit the allegation to the State Agency until the following morning, well beyond 2 hours after the allegation was made, contrary to the facility’s abuse prevention policy and federal requirements.
A resident with PTSD and intact cognition reported that a CNA grabbed the resident’s arm hard enough for the resident to feel the CNA’s nails on the skin. The facility’s abuse policy required interviewing the person who reported the incident, any witnesses, and involved staff, but the investigation did not include a statement from the LPN who first received the allegation or from an agency CNA who reported witnessing the interaction and said they had described it to the nurse on duty. The facility’s investigation conclusion referenced varying statements and could not conclusively determine the cause of a scratch, yet key interviews required by policy were not completed.
A resident with severe cognitive impairment and multiple comorbidities, fully dependent on staff for ADLs, had a care plan requiring staff-assisted showers twice weekly and toileting/check-and-change every 2 hours. Review of shower sheets and CNA task documentation showed several scheduled shower days with no recorded bathing or showering. Review of a 2-hour check-and-change log and CNA bowel/bladder documentation revealed prolonged periods with no documented checks or changes, despite the care plan requirement. Staff interviews confirmed expectations for twice-weekly showers and 2-hour continence checks but revealed inconsistent understanding of the purpose and duration of the paper logs. A social services staff member reported personally noticing the resident sitting in a common area most of the day and detecting an odor, consistent with concerns later raised by the family.
A resident with chronic respiratory failure and multiple psychiatric and pain-related diagnoses reported severe abdominal and low back pain, was crying, and rated the pain 10/10. An RN contacted the NP, who ordered hospital transfer, but the resident refused; despite this significant change in condition and uncontrolled pain, there is no documentation of an RN assessment, vital signs, or ongoing monitoring, even though the care plan required monitoring for respiratory changes and the facility’s change of condition policy required assessment and documentation. By the next day, the resident had rapid respirations, increased pain, altered mental status, and could not sit at the edge of the bed; 911 was called and the resident was sent to the ER and admitted to the ICU with pneumonia, acute on chronic respiratory failure, sepsis, and septic shock. The resident later reported that staff did not listen to her repeated complaints over about a week and that no assessment or monitoring occurred on the day of her severe pain, while the DON confirmed there was no documentation of further assessment or monitoring on either day.
Multiple residents reported and surveyors observed that there were not enough CNAs to meet daily care needs, resulting in prolonged call light response times, missed ROM exercises for a resident with quadriplegia, and failure to reposition a resident with paraplegia and a stage 4 sacral pressure injury according to the care plan. One resident described waiting up to an hour for assistance on and off the commode with a Hoyer lift, causing discomfort and skin indentations, while another reported waiting so long for toileting assistance that they had an accident and felt humiliated. Surveyors documented call lights remaining unanswered for 10–32 minutes and noted staff turning off a call light and leaving without immediately providing requested incontinent care. CNAs confirmed that due to insufficient staffing they could not complete all required tasks, including repositioning, ROM, and oral care, and reported being too busy to take breaks.
The facility failed to maintain clean, safe, and comfortable living conditions for three residents, as evidenced by persistent dirt, debris, and disrepair in their rooms and a shared bathroom despite written daily cleaning requirements. One resident’s room had dried food spots, splattered substances, and trash on the floor; another resident reported her room was filthy and dusty, with surveyors observing dust, dirty shoe prints, debris, and a wall heater pulling away from the wall; a third resident’s room had dirty shoe prints, tube-feeding liquid splatters on equipment, paper debris, and a wall heater that had fallen down the wall. The shared bathroom used by two residents contained feces in the toilet, dried brown drips on the seat, and a urine collection container and compression stockings resting on a discolored cloth with dried urine. Review of cleaning logs showed multiple days where required cleaning tasks were not completed, and staff interviews confirmed that rooms were not consistently cleaned and that housekeeping did not move personal items to clean surfaces, while maintenance was unaware of the wall heater issues.
A resident with stroke, diabetes, COPD, CHF, pulmonary hypertension, right-sided weakness, aphasia, and dependence on staff for toileting was the subject of a neglect allegation after a family member reported the resident was not being changed, was spoken to rudely by a CNA, and was not given water. The facility’s investigation documentation did not show that other residents were interviewed about their care by CNAs, despite policy requiring interviews of all involved persons and others who might have knowledge of the allegation. The DON later produced resident interviews, but follow-up revealed these were conducted weeks later rather than at the time of the incident, and the Administrator acknowledged that resident interviews were not obtained during the original investigation.
A resident with orders for G-tube administration of potassium citrate-citric acid for kidney stones, oxybutynin for urinary leakage, and gabapentin for pain did not receive these medications within the facility’s required one-hour window around the scheduled administration time. Audit records showed that all three medications scheduled for 8:00 AM were given at 9:18 AM, outside the defined 7:00–9:00 AM window. In interviews, an LPN and the DON confirmed that doses given outside this timeframe are considered medication errors, demonstrating that pharmaceutical services were not provided in accordance with physician orders and facility policy.
Two residents with existing pressure injuries did not receive care consistent with their care plans and facility policy. One resident with multiple sclerosis, paraplegia, and a stage 4 sacral pressure injury was observed lying on her back in the same position for many hours without being turned or repositioned every 1–2 hours as ordered, and CNAs later confirmed they had not repositioned her during that period. Another resident with CHF, peripheral vascular disease, vascular dementia, protein-calorie malnutrition, and a stage 4 pressure injury on the left great toe had care plan interventions including a pressure-reducing mattress, foot cradle, and Prevlon boots while in bed, but was observed in bed with the air mattress and foot cradle in place while the pressure-relieving boots were on the floor instead of on the resident’s feet, despite the DON acknowledging the boots should be worn in bed to off-load pressure.
Failure to Provide Adequate Supervision, Fall Investigation, and Smoking Safety Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents, including falls and smoking-related hazards, for multiple residents. One resident with encephalopathy, vertigo, mild neurocognitive disorder, chronic pain syndrome, and moderately impaired cognition (BIMS score 11) had been assessed as high risk for falls and was recommended by therapy to use a two-wheeled walker (2WW) with supervision for all mobility due to vertigo and cognitive impairment. The resident’s care plans referenced use of a 2WW with staff assistance for toileting and short distances and a wheelchair for long distances, but the care plan was not revised after the ADL evaluation and therapy discharge to clearly reflect the current level of assistance and supervision required. Surveyors repeatedly observed this resident ambulating in the hallway without a walker, and staff reported that the resident sometimes used a walker and sometimes did not, depending on how the resident felt, without consistent staff supervision or redirection to use the walker. Another deficiency involved a resident who smoked and had COPD, depression, and a cognitive communication deficit, with intact cognition (BIMS 14) and minimal assistance needs for ADLs. The facility’s smoking policy required evaluation of safe smoking status on admission and quarterly, including whether the resident could smoke safely with or without supervision and whether the resident could retain smoking materials. For this resident, only an admission smoking assessment and one quarterly assessment were located, and there were no documented quarterly smoking assessments for other quarters. Both available assessments and the smoking care plan lacked documentation specifying whether the resident was to smoke supervised or unsupervised and whether the resident or the facility should hold the smoking materials. Staff interviews indicated the resident typically went outside to smoke alone and retained personal smoking materials, and staff were unsure how often smoking assessments were to be completed or who was responsible for them. The facility also failed to thoroughly investigate falls for two other residents at high risk for falls. One resident with paraplegia, morbid obesity, and severe cognitive impairment (BIMS 4) had a documented fall in the room that was unwitnessed, resulting in a bruised left eye and nosebleed. The post-fall evaluation documented that the resident was reaching for items at the time of the fall, was wearing socks, and was not using prescribed assistive devices or oxygen, but the fall investigation form stated the resident was unable to describe the event, listed no predisposing environmental, physiological, or situational factors, and contained only a brief second-hand statement without clear identification of witnesses or staff involved. The investigation did not document when the resident was last seen, whether the fall was from bed, wheelchair, or chair, what fall-prevention interventions were in place at the time, or any root cause or new interventions. Another resident, in a comatose state with impaired range of motion in all extremities, dependent for all ADLs, and assessed as at risk for falls, was found face down on the floor next to the bed with an abraded area on the right forehead after an unwitnessed fall. Documentation later described the resident on the floor on the left side of the bed in a supine position with all equipment intact and no apparent injuries, and the resident was transported to the ER. The post-fall evaluation and fall investigation forms indicated no identified environmental, physiological, or situational predisposing factors and did not identify a root cause. Staff statements documented that two agency CNAs and a respiratory therapist had repositioned the resident shortly before the fall and then found the resident on the floor minutes later, with adaptive devices such as a low bed, wedges, and boots in use. The DON later described a possible mechanism involving coughing, air mattress positioning, and a loose sheet, but this explanation and a clear root cause were not documented in the formal fall investigation, and the facility could not provide additional information explaining how a resident without bed mobility fell from the bed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of abuse was reported to the State Agency within the required 2-hour timeframe after the allegation was made. Facility policy, titled “Abuse Prevention Program” and effective 1/23/26, requires that all alleged violations involving abuse be reported immediately, but not later than two hours, to the State Agency and other appropriate agencies. Despite this policy, the Nursing Home Administrator (NHA) did not report an allegation of physical abuse involving a resident and a CNA until several hours after first being informed of the concern. The resident involved, identified as R6, had been admitted on 6/25/2015 with diagnoses including post-traumatic stress disorder and had a legal guardian. R6’s most recent MDS documented a BIMS score of 15, indicating intact cognition. On the evening of 2/9/26, around 7:30 PM, R6 reported to an LPN that a CNA had grabbed R6’s arm and that R6 felt the CNA’s nails on the skin. The LPN stated that shortly after receiving this report, the LPN contacted the NHA and the DON, asking what should be done. The LPN reported being instructed by the NHA to obtain a statement from the resident and perform a skin check, which the LPN completed and provided to the NHA. The NHA acknowledged receiving a text from the LPN around 11:00 PM on 2/9/26 asking what to do if a resident reports abuse, and directed the LPN to get a statement and send it. The NHA stated that no information about potential physical contact was received until the morning of 2/10/26 and that the allegation was reported to the State Agency at 6:16 AM on 2/10/26 via email after the reporting website was not working. Surveyor review of the Facility Reported Incident showed the initial allegation of abuse was submitted to the State Agency at 2:16 PM on 2/10/26. The surveyor determined that the facility did not ensure the alleged violation involving abuse was reported to the State Agency immediately, and not later than 2 hours after the allegation was made, as required by facility policy and regulatory requirements.
Failure to Thoroughly Investigate Alleged Physical Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an alleged incident of physical abuse involving resident R6 and CNA-BB, as required by the facility’s Abuse Prevention Program policy. R6, who has PTSD and a BIMS score of 15 indicating intact cognition, alleged that CNA-BB grabbed R6’s arm and that R6 felt CNA-BB’s nails on the skin. The facility’s policy requires that the individual conducting an abuse investigation interview the person reporting the incident, any witnesses, and staff on all shifts who had contact with the resident during the period of the alleged incident. The facility’s investigation conclusion stated that it was unable to conclusively determine that a scratch was from physical contact between R6 and CNA-BB due to varying statements, but that it was prudent to deduce the scratch occurred from the CNA making contact with the resident’s arm. Despite these requirements, the investigation did not include an interview or statement from LPN-AA, who first received R6’s report of the alleged abuse and notified the NHA and DON, nor from CNA-CC, an agency CNA who reported witnessing the interaction between R6 and CNA-BB and stated having explained what happened to the nurse on duty. LPN-AA reported that, after being informed by R6 of the alleged arm grabbing, LPN-AA contacted the NHA and DON and was instructed by the NHA to obtain a resident statement and perform a skin check, which was done and provided to the NHA. CNA-CC confirmed caring for R6 on the date of the incident and stated that the facility did not contact CNA-CC for a statement about the alleged incident. The surveyor confirmed that the facility’s submitted investigation lacked statements or interviews from both the reporting nurse and the witnessing CNA, and the NHA acknowledged that a statement from CNA-CC was not obtained.
Failure to Provide Scheduled Showers and 2-Hour Check-and-Change for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide required Activities of Daily Living (ADL) services, specifically bathing and toileting, to a resident who was fully dependent on staff for care. The resident had diagnoses including bladder cancer, cerebral infarction (stroke), Alzheimer’s disease, vascular dementia, and depression, and was documented as severely cognitively impaired and dependent on staff for all care, mobility, and transfers. The resident’s ADL care plan, initiated 4/14/22, required staff assistance of one person for bathing/showers, with showers scheduled twice weekly on Tuesdays and Saturdays, and instructions to offer an alternative if a bath or shower was refused. The facility’s ADL support policy required that residents unable to carry out ADLs independently receive appropriate hygiene and toileting assistance in accordance with the plan of care. Surveyors reviewed the resident’s shower and bathing documentation for December 2025, January 2026, and February 2026, including shower sheets and CNA task documentation. They identified multiple dates on which the resident was scheduled to receive showers but there was no documentation that bathing or showering occurred, specifically on four scheduled shower days in January and February 2026. Interviews with CNAs and the ADON confirmed that residents were supposed to receive showers twice weekly, that shower days and shifts were listed in a binder at the nurse’s station, and that CNAs were responsible for documenting showers or bed baths on shower sheets and in the electronic medical record (EMR), with nurses completing skin checks and forwarding completed shower sheets to the DON. The resident’s care plan also included a toileting intervention from the fall care plan to review and revise a toileting program with checks and toileting every two hours and as needed. Surveyors reviewed an every-2-hour check and change log dated 2/17/26–2/20/26 and found multiple blank rows with no documentation, showing that on 2/17/26 the resident was not checked or changed from sometime before noon until 10 PM (at least 10 hours), and on 2/18/26 from 6 AM until 2 PM (8 hours). CNA bowel and bladder documentation in the EMR showed long gaps with no entries, including over 15 hours on 2/17/26 and almost 17 hours between the evening of 2/17/26 and the afternoon of 2/18/26. Staff interviews revealed inconsistent explanations about the purpose and duration of the check and change logs, with some CNAs stating they had been used long term for every two-hour checks and an ADON stating they were short-term tools without a formal policy. The Director of Social Services reported personally noticing the resident sitting in the common area most of the day and detecting an odor, and later learning that the family had raised the same concern, supporting the surveyor’s conclusion that the resident was not checked and changed every two hours as care planned.
Failure to Assess and Monitor Resident After Severe Pain and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and the facility’s own change of condition policy. The Wisconsin Nurse Practice Act (N6.03) requires RNs to use the full nursing process—assessment, planning, intervention, and evaluation—while the facility’s Change of Condition policy requires prompt notification of the practitioner for uncontrolled pain or need for hospital transfer, and completion of an assessment with documentation of findings, including vital signs and pain. On one date, the resident reported increased abdominal and low back pain, was crying, and rated the pain as 10/10. The nurse contacted the NP, who ordered the resident sent to the hospital, but the resident refused transfer. Despite this significant change in condition and uncontrolled pain, there is no documentation that an RN assessment was completed or that nursing staff continued to monitor the resident’s condition. The resident had multiple chronic conditions, including bipolar disorder, other chronic pain, low back pain, fibromyalgia, schizoaffective disorder, generalized anxiety disorder, psychophysiologic insomnia, and adjustment disorder. The resident’s MDS showed a BIMS score of 15/15, indicating intact cognition. The comprehensive care plan identified altered respiratory status/difficulty breathing related to chronic respiratory failure, restrictive lung disease, and obstructive sleep apnea, with interventions including CPAP per MD orders, elevating the head of bed, and monitoring for and documenting changes in orientation, restlessness, anxiety, air hunger, and signs and symptoms of respiratory distress such as increased respirations, decreased pulse oximetry, tachycardia, restlessness, diaphoresis, headache, lethargy, confusion, hemoptysis, cough, pleuritic pain, and accessory muscle use. Despite these care plan directives, there is no evidence in the medical record that the resident was assessed or monitored after reporting severe pain on the first day. On the following day, a CNA summoned the nurse to the resident’s room at approximately 7:00 AM. The resident was unable to sit at the edge of the bed unassisted, had rapid respirations, increased pain, and altered mental status. The nurse confirmed with the resident that she now agreed to transfer to the ER, and 911 was called; the resident left via ambulance around 7:30 AM. The resident was admitted to the hospital ICU with diagnoses including pneumonia, acute on chronic respiratory failure, sepsis with acute hypoxic respiratory failure, and septic shock. Hospital documentation noted that the resident reported worsening dyspnea over the prior 24 hours, was in mild to moderate respiratory distress with increased work of breathing, low-grade fever, mild tachycardia, and later became hypotensive, requiring sepsis fluid bolus, IV fluids, IV pressors, and non-invasive ventilation. There is no evidence in the facility record that a nurse completed an assessment on the morning of transfer, beyond the resident’s report that only a temperature was taken and no other vital signs were obtained. In interviews, the resident stated she had been telling staff for about a week, multiple times per day, that she did not feel well and thought she had a urinary infection, and that staff did not listen. She reported that there was no assessment or monitoring on the day she first reported severe pain, and that on the following day she was "out of it" and unable to sit up, and that before transfer the nurse only took her temperature. The RN who worked on the first day stated she recalled the resident refusing to go to the ER and thought she might have done an abdominal assessment but could not remember and could not recall what she had documented. The DON confirmed that there was no documentation of further assessment or monitoring on either day and stated she would have expected the nurse to take vital signs, complete an assessment at least every shift, and enter a progress note. The lack of documented RN assessment, ongoing monitoring, and vital signs in response to the resident’s uncontrolled 10/10 pain and subsequent deterioration constitutes the cited failure to provide care in accordance with professional standards and facility policy.
Insufficient Nursing Staff Leading to Unmet Care Needs and Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ assessed needs and care plan interventions, resulting in unmet care needs and prolonged call light response times. The facility’s own “Sufficient Staffing” policy requires adequate nursing staff with appropriate competencies, daily review of staffing patterns, and adjustment of staffing based on census and resident acuity. Despite this, multiple residents and staff reported that there were not enough CNAs and that essential care tasks were not completed because staff were too busy. Surveyors directly observed long call light wait times on the unit, with call lights remaining unanswered for extended periods while staff were either not present on the hall or engaged in other activities. One cognitively intact resident reported waiting up to 45 minutes for call lights to be answered and described staff entering the room, stating they would return, and then not coming back for more than an hour, leaving needs unmet. Another cognitively intact resident with quadriplegia and physician orders and care plan interventions for daily active assisted ROM to the bilateral lower extremities stated that CNAs did not perform the ROM exercises as ordered because they were too busy. During a surveyor observation of this resident’s call light, staff entered the room within a few minutes, turned off the call light, told the resident they would notify a CNA about the need for incontinent care, and then left; incontinent care was not provided until approximately 24 minutes after the initial call light activation. CNAs later confirmed they had not completed the resident’s ROM exercises that day due to being too busy. Another resident with multiple sclerosis, paraplegia, a stage 4 sacral pressure injury, and a care plan requiring turning and repositioning at least every 1–2 hours was observed lying on her back in the same position over several hours, from early morning through early afternoon. CNAs assigned to her care acknowledged that she should be repositioned every 2 hours and admitted that she had not been repositioned during the shift until cares were provided around 2:00 PM, stating they did not always have time to reposition her. A different resident reported that there was one CNA for 20 residents and described waiting up to 1.5 hours for assistance to use the bathroom, resulting in an accident that made the resident feel terrible, humiliated, and disrespected. Surveyors also documented multiple call lights active for 10–32 minutes before being answered, including one instance where a nurse manager walked past a room with an active call light without responding. A further cognitively intact resident with lymphedema, fibromyalgia, chronic pain, morbid obesity, and a care plan requiring two staff for all cares and use of a Hoyer lift to and from the commode reported that there were not enough staff, especially on evening and night shifts. This resident stated she had to wait up to an hour for staff to answer her call light or assist her off the commode, and that prolonged time on the commode caused numbness in her right hip and leg and purple discoloration on the backs of her legs. She also reported sitting on a Hoyer sling all day, causing painful indentations, and stated that when she complained, staff became sarcastic, so she stopped voicing concerns. CNAs interviewed by surveyors stated there were not enough staff to complete all resident care needs, specifically citing that repositioning, ROM, and oral care often did not get done because there was too much to do, and that they were unable to take breaks due to workload, further confirming that staffing levels were insufficient to meet residents’ care plan requirements and daily needs.
Failure to Maintain Clean and Safe Resident Rooms and Shared Bathroom
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment for multiple residents, as required by its own cleaning policies and checklists. The facility’s Cleaning Checklist for Elderly Home and Daily Cleaning Checklist require daily cleaning of resident rooms, including dusting, disinfecting high-touch surfaces, sweeping and mopping floors, and cleaning and sanitizing bathrooms. However, review of the Daily Cleaning Checklists for the hallway where the affected residents lived showed multiple days where required cleaning tasks were left blank, indicating that rooms and bathrooms were not consistently cleaned as specified. One resident reported that her room was not clean, and the surveyor observed dark, dried food spots on the floor, splatters of red/brown dried substances under the bedside table, a long piece of string on the floor, and an alcohol prep pad wrapper near the sink. Another resident stated that the facility was not kept clean, described her room as filthy and dusty, and said staff did not clean the sink counter or move items to clean under them. In that room, the surveyor observed dust on the over-bed light, a granola bar wrapper under the bed, dirty shoe prints on the floor, crushed white powder on the floor near the nightstand, a wall heater pulling away from the wall with paint ripping, and a cluttered, untidy sink counter. A third resident’s room was observed with dirty shoe prints on the floor, brown tube-feeding liquid splatters on the feeding pole, a wall heater that had fallen down the wall causing paint to rip, and paper debris under the head of the bed. The shared bathroom for two of the residents contained feces in the toilet bowl, dried brown drips on the toilet seat, and a graduated cylinder used for urine collection sitting upside down on a discolored disposable cloth with dried urine, along with tubigrip stockings on the same cloth. On a subsequent day, the surveyor found that these rooms and the shared bathroom remained in essentially the same unclean condition, with only a granola bar wrapper removed from one room, confirming that the facility did not ensure daily cleaning as required. Staff interviews further confirmed that rooms were not kept clean and that housekeeping did not move resident belongings to clean surfaces, while maintenance staff were unaware of the deteriorating wall heaters and relied on staff work orders rather than ongoing room audits during occupancy.
Failure to Conduct Timely and Thorough Neglect Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident. The resident had been readmitted with diagnoses including stroke and diabetes, and had an ADL care plan indicating an ADL self-care deficit related to COPD, CHF, pulmonary hypertension, right-sided weakness, and aphasia, with an intervention requiring assist of two for toileting. A significant change MDS with an ARD of 01/16/26 showed the resident had a BIMS score of 10/15, indicating moderately impaired cognition, and was dependent on staff for toileting. A facility investigation dated 01/14/26 documented that a family member reported the resident had not been changed, was calling more often to express concerns, that a CNA spoke to the resident in a rude manner, and that water was not given to the resident. Review of the investigation file showed no evidence that other residents had been interviewed to determine if they had concerns about care provided by CNAs, despite the facility’s abuse, neglect, and exploitation policy requiring identification and interviews of all involved persons, including others who might have knowledge of the allegations. When the DON was asked about resident interviews, the DON later produced interviews but stated they were thought to be in another folder. Follow-up on 02/23/26 revealed that the identified residents had actually been interviewed on that date, not at the time of the original investigation. On 02/25/26, the Administrator acknowledged that resident interviews were not obtained at the time of the investigation, demonstrating that the facility did not conduct an immediate and complete investigation as required by its policy.
Untimely Medication Administration Resulting in Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely administration of medications in accordance with physician orders and facility policy for one resident. The facility’s “Administering Medications” policy required medications to be administered per provider orders, with verification of the right medication, dose, route, time, and resident identity, and specified that medications should be administered within one hour of the prescribed time. The “Medication Error and Drug Interactions” policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order. For the resident reviewed, physician orders for February 2026 included Potassium Citrate-Citric Acid oral solution via G-tube four times daily for kidney stones, Oxybutynin Chloride oral solution via G-tube three times daily for urinary leakage, and Gabapentin oral solution via G-tube three times daily for pain. Record review of the Medication Administration Audit Report showed that all three medications, scheduled for 8:00 AM on a specific date, were actually administered at 9:18 AM, which was outside the facility’s defined one-hour window (7:00 AM to 9:00 AM) for an 8:00 AM dose. During interviews, an LPN and the DON both confirmed that medications scheduled for 8:00 AM must be given between 7:00 AM and 9:00 AM, and that administration outside this timeframe constitutes a medication error. This late administration of the resident’s ordered medications, beyond the facility’s established administration window, resulted in a medication error and demonstrated that pharmaceutical services were not provided in accordance with the facility’s own policies and the prescriber’s orders.
Failure to Implement Repositioning and Off-Loading Interventions for Residents With Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury care and prevention consistent with its own policy and professional standards for two residents with existing pressure injuries. The facility’s Pressure Injury Prevention and Wound Care Management policy requires identification of risk factors, implementation of appropriate interventions, and individualized repositioning based on clinical condition, with the expectation that residents with pressure injuries receive care to promote healing and prevent additional ulcers. Despite this, staff did not follow the established care plans and interventions for the residents reviewed. One resident, admitted with multiple sclerosis, paraplegia, and a stage 4 sacral pressure injury, had a care plan that identified limited physical mobility and risk for altered skin integrity, with an intervention to turn and reposition the resident at least every 1–2 hours. On the survey date, the resident was repeatedly observed lying on her back in bed with the head of the bed elevated about 45 degrees at multiple times from 8:00 AM through 1:14 PM, without evidence of repositioning. Certified nursing assistants later confirmed they had not provided cares or repositioned the resident during that time, and one CNA stated she did not reposition the resident until about 2:00 PM. Nursing leadership, including the ADON and DON, stated that residents with pressure injuries should be repositioned every 1–2 hours and that this resident should have been repositioned per her care plan. Another resident, admitted with congestive heart failure, peripheral vascular disease, vascular dementia, and protein-calorie malnutrition, had a care plan identifying risk for altered skin integrity and a stage 4 pressure injury on the left great toe. Interventions included use of a foot cradle, a pressure-reducing air mattress, management of clinical conditions, and Prevlon boots to the feet while in bed, along with turning and repositioning every 2–3 hours. The wound care physician documented a stage 4 pressure wound of the left first toe with an etiology of pressure and an approach of close monitoring and off-loading. During an interview, the resident, who was cognitively intact, reported having a pressure injury on the foot and stated staff have them wear boots during the day and off at night; however, the surveyor observed the resident lying in bed with an air mattress and foot cradle in place, but the pressure-relieving boots were on the floor instead of on the resident’s feet. The DON later stated that the root cause of the pressure injury was pressure from blankets and that a foot cradle had been initiated to off-load the blankets, and confirmed the resident should be wearing the boots when in bed.
Some of the Latest Corrective Actions taken by Facilities in Wisconsin
- Educated all staff on the facility smoking policy including resident eligibility and safe smoking practices (K - F0689 - WI)
- Revised and updated the smoking policy to add requirements for residents who elected to self-store smoking materials (demonstrated safe management and use of a locked storage box per the plan of care) (K - F0689 - WI)
- Educated staff on proper storage of resident smoking materials at the nurses station or in approved locked boxes per the resident’s plan of care (K - F0689 - WI)
- Trained staff on immediate actions for unsafe smoking including redirection to securing materials, addressing oxygen risks, and notifying leadership (K - F0689 - WI)
- Reeducated residents who smoked on the smoking policy and requirements for keeping smoking materials (K - F0689 - WI)
- Established random audits by the Administrator or designee of residents who smoked to monitor safe smoking and policy compliance, completion of assessments, care plan updates, and correct storage of smoking materials (K - F0689 - WI)
- Directed QAPI review of audit results for further recommendations (K - F0689 - WI)
Failure to Control Smoking Materials and Supervise Unsafe Smoking, Including Oxygen-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and control of smoking materials, particularly for a resident using oxygen, in violation of its own smoking safety policy. One resident with COPD and chronic hypoxic respiratory failure, who required long‑term oxygen for survival benefit per physician notes, began smoking after years of not smoking. Nursing notes documented that this resident had recently started smoking, was smoking frequently, and was observed smoking in unsafe locations, including inside the building between doors and outside the main entrance rather than in the designated smoking area. Despite multiple staff observations and documentation of this new smoking behavior, the resident did not have a Resident Safe Smoking Assessment or a smoking-related care plan, and the physician’s oxygen orders referenced in progress notes were not present on the MAR/TAR. Staff documented repeated episodes of unsafe smoking by this oxygen‑dependent resident. Notes described the resident smoking outside with another resident, smoking so frequently that he missed meals and did not sleep, being caught smoking inside the doors with cigarette butts on the floor, and refusing to move to the designated smoking area even after being informed the facility was non‑smoking and that other residents with oxygen used the same entrance. On one occasion, police were called when the resident refused to comply with smoking restrictions at the main entrance. Later, the facility self‑reported that at approximately 3:00 AM the resident was found in his room smoking while oxygen was in use. Staff intervened, the resident refused to relinquish smoking materials, became physically aggressive, and bit a nurse’s hand while staff attempted to remove the lighter. Another nurse note documented a separate incident in which the same resident was again smoking in his room, refused to extinguish the cigarette, and began putting it out on window drapes after staff removed oxygen from the room for safety. The facility’s own smoking policy required that smoking be limited to designated areas, prohibited oxygen use in smoking areas, mandated a Resident Safe Smoking Assessment for smokers, and required that smoking materials be maintained by nursing staff. However, the resident who had recently started smoking and was known to use oxygen had no smoking assessment, no smoking care plan, and continued to have access to smoking materials in his room. Leadership acknowledged that a safe smoking assessment was not completed, the care plan was not updated with smoking goals and interventions, and oxygen orders were not on the MAR/TAR even though staff continued to use oxygen. Additionally, surveyors observed another deficiency when one resident handed a lighter to another resident in the hallway while an LPN remained seated at the nurse station and stated that residents had the right to keep their own smoking materials, contrary to the DON’s statement that residents were to return smoking materials to staff and not hand them off to other residents. These actions and inactions show that the facility failed to secure smoking materials per policy, failed to assess and care plan for residents who smoke, and failed to ensure staff followed established smoking safety procedures.
Removal Plan
- Educated all staff on the facility smoking policy, including resident eligibility and safe smoking practices.
- Revised the smoking policy to include provisions for residents who elect to self-store smoking materials, requiring residents to demonstrate safe management and use a locked storage box in accordance with the plan of care.
- Educated staff on proper storage of resident smoking materials at the nurses station or in approved locked boxes per the resident's plan of care.
- Trained staff on immediate actions for unsafe smoking, including redirection to securing materials, addressing oxygen risks, and notifying leadership.
- Reeducated all residents who smoke on the smoking policy and requirements for keeping materials.
- Generated a comprehensive list of all residents who expressed a desire to smoke.
- Completed a smoking evaluation for each identified resident, including care plan revisions and offering smoking cessation.
- Reviewed and updated the smoking policy.
- Administrator or designee to conduct random audits of residents who smoke to ensure safe smoking and policy compliance, assessments completed, care plans in place or updated as appropriate, and correct storage of smoking materials.
- Review audit results at QAPI for further recommendations.
Failure to Assess, Order, and Care Plan Indwelling Catheter Leading to Septic Shock from UTI
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with urinary incontinence received a comprehensive assessment, physician orders, and care planning for an indwelling urinary catheter. The resident was admitted with severe cognitive impairment, anoxic brain damage, acute and chronic respiratory failure, COPD, heart failure, and was documented on the admission MDS and CAA as always incontinent of bladder and dependent on staff for all ADLs and incontinence care. A care plan was initiated for bladder incontinence related to anoxic brain damage, but there was no documented indication at admission for an indwelling catheter. Subsequent MDS assessments documented that the resident had an indwelling catheter, and the MAR instructed staff to record Foley output every shift, yet the medical record contained no physician order for the catheter, no documentation of when the catheter was first placed, and no comprehensive care plan addressing indications for use or required catheter care. Nursing notes showed abnormal lab results, including low hemoglobin and hematocrit, and an elevated WBC count initially attributed to recent prednisone use, with repeat labs ordered. Later, the resident was noted to be hypotensive with increased oxygen needs and secretions, and was sent to the hospital. The hospital discharge summary for that hospitalization documented treatment for septic shock secondary to UTI. When the resident returned from the hospital, there was still no order for the catheter and no care plan directing catheter care and treatment. Months later, a physician order was finally obtained for a 16 French indwelling catheter to promote wound healing, followed by an order to irrigate the Foley catheter twice daily, and only then was a catheter-related care plan developed. The DON later stated that she believed the resident had returned from an earlier hospitalization with a catheter and that nurses did not obtain an order or assess the need for its use, and that she had no explanation for the lack of assessment and orders. The facility’s failures contributed to the resident developing septic shock secondary to UTI due to the indwelling catheter, resulting in a finding of immediate jeopardy beginning on a specified date.
Removal Plan
- All facility nurses re-educated on ensuring that all residents with a foley catheter have an order for the foley catheter along with standard foley catheter orders such as catheter changes, catheter flushing, changing graduate, having a barrier under graduate when draining bag, changing catheter drainage bag, etc.
- Director of Clinical Services (DCS) to assist with providing and explaining re-education to facility nurses.
- DCS assisted with providing 1:1 education with Interdisciplinary team nurses to facilitate and ensure understanding and expectations of processes and policy related to catheter care/orders and to include updating care plans.
- DCS(s) will assist with updating/creating individualized care plans.
- Nursing staff re-educated to complete foley catheter care q shift and prn.
- Nursing staff re-educated about changing out catheter materials biweekly and prn.
- Policy used as reference and guide during training.
- All training to floor staff to be completed by their next working shift.
- Audits will be conducted by DCS or designee on admissions and re-admissions with foley catheters to ensure foley catheter diagnosis and care orders are in place and that foley catheters are care planned appropriately per policy.
- Audits will be conducted by DCS or designee to ensure competency and compliance with catheter care.
- Audits will be conducted to ensure compliance with changing out catheter care materials biweekly.
- DCS or designee will review/audit POC charting Monday through Friday (Monday will include 72 hr review) to review catheter care tasks not completed; ad hoc education will be provided as indicated by DCS or designee for catheter care tasks not completed.
- Audits will be reviewed at the monthly QAPI meeting to determine trends or patterns of concern and/or if further education is needed until substantial compliance has been achieved.
Failure to Prevent Resident-to-Resident Sexual Abuse by Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by another resident with a known history of inappropriate sexual behavior. One resident (R1), who had a documented history of touching other male residents inappropriately, was initially placed on 1:1 supervision after incidents on 4/27/25 and 4/28/25 in which he was found with his hands in other male residents’ briefs or crotch areas, touching their genitals. Over the following months, the facility progressively reduced R1’s supervision from 1:1 to 15‑minute checks, then to one‑hour checks, then to two‑hour checks, and ultimately discontinued his supervision entirely on 12/12/25, despite his history of sexually inappropriate conduct. R1’s medical record shows multiple medical conditions, including hemiplegia and hemiparesis following a stroke, diabetes mellitus, hypertension, and other cardiovascular conditions. His MDS documented a BIMS score of 10, indicating moderate cognitive impairment, and noted physical and verbal behaviors directed toward others. His care plan identified a behavior problem of inappropriate sexual conduct with other residents and inappropriate comments to staff, and included interventions such as providing care in pairs and, later, specific directions to intervene, remove him from other residents’ rooms, and protect the rights and safety of others. Staff interviews confirmed that R1 was known to be sexually inappropriate, particularly with male residents, and that interventions such as 1:1 supervision when up in his wheelchair, 15‑minute checks when in bed or recliner, and a door alarm were in place at the time of the survey. On 1/18/26, after supervision had previously been discontinued and then later re‑implemented, R1 was found in another resident’s (R2’s) room inappropriately touching R2 in his private area under his clothing. R2, who had diagnoses including acute respiratory failure with hypoxia, COPD, sepsis, Alzheimer’s disease, and hypertension, was documented as cognitively intact on his MDS, able to understand and be understood, and having no behaviors. Witness accounts from staff indicated that R1’s hand was inside R2’s pants, touching R2’s penis and upper thigh, and R2 stated that the touching was not consensual. The facility’s abuse, neglect, and exploitation policy required prevention of abuse, identification and monitoring of residents with behaviors that might lead to conflict, and increased supervision to protect residents from harm, but the facility’s reduction and discontinuation of R1’s supervision, despite his known history of sexually inappropriate behavior, led to the incident of non‑consensual sexual contact. Surveyors determined that this failure to provide adequate supervision and protect residents from sexual abuse created a reasonable likelihood for serious psychosocial harm and resulted in a finding of Immediate Jeopardy beginning on 1/18/26.
Removal Plan
- Residents were separated and the incident was reported to the NHA.
- Staff provided statements; additional staff interviews were completed as needed.
- Law enforcement responded and interviewed the residents.
- Residents had mood, behavior, and appetite monitored.
- Residents received skin assessments.
- Residents’ physicians were updated; the POA was updated; the resident who is their own decision maker declined notification.
- All residents on the wing with a BIMS less than 7 received skin checks.
- All residents with a BIMS greater than 7 were interviewed.
- The resident was placed on 1:1 supervision when up in a wheelchair.
- The resident was placed on 15-minute checks when in bed or recliner.
- Alarms were implemented on the resident’s door and at ground level to alert staff.
- Residents’ psychosocial well-being care plans were updated.
- Resident relationship, intimacy, and sexuality histories were completed; both residents denied wanting a relationship.
- Staff education was initiated regarding abuse with emphasis on sexual abuse, 1:1 definition and expectations, resident-specific interventions, and 15-minute checks; charge nurse and leadership ensured staff were educated prior to the start of their shifts.
- The social worker interviewed the residents and both stated they feel safe.
- The DON and VP of Nursing interviewed the resident and the resident stated they feel safe.
- BCS services were offered to the residents and both declined.
- The resident was offered materials to help with hypersexuality and declined.
- A care plan meeting was held with the resident, the facility, and the POA to discuss behaviors, the plan moving forward, and activities of interest.
- The Medical Director was updated regarding the incident between the residents.
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