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 conduct a thorough investigation after two residents with dementia were found in a common area with one resident’s hand partially down the other’s brief and moving back and forth, while the second resident appeared unaware. An activities staff member immediately separated the residents and reported the event, but the facility’s follow-up was limited to that single witness statement. Despite a written abuse policy requiring prompt, comprehensive investigations with interviews of all potential witnesses and others who might have relevant information, the facility did not interview additional staff or residents, did not explore whether the involved resident had a history of similar behaviors, and did not determine whether other residents might have been affected.
A cognitively intact resident with multiple chronic conditions gave an agency LPN a small amount of cash for gas after the LPN stated they could not get home without money. Another nurse instructed the LPN to return the money, and the resident later confirmed to the ADON that the money had been given and returned, explaining they knew the LPN from a prior facility and believed their relationship made the gift acceptable. The ADON reported the incident to the NHA, but the NHA decided it was not an allegation of exploitation and did not report it to the State Agency, contrary to the facility’s abuse, neglect, and exploitation reporting policy.
A resident with multiple chronic conditions and intact cognition reported giving an agency LPN a small amount of cash for gas after the LPN stated they could not get home, and the money was later returned. The facility’s policy requires immediate, comprehensive investigation of alleged abuse, neglect, or exploitation, including interviewing all involved persons and potential witnesses. However, after confirming the exchange of money with the resident, the ADON did not pursue further investigation, and the NHA determined it was not an exploitation allegation and did not interview other residents or staff to identify any similar concerns, resulting in a failure to conduct a thorough investigation as required by facility policy.
A resident with osteomyelitis, diabetic foot ulcers, Parkinson’s disease, and moderate cognitive impairment, care planned as at risk for falls due to weakness, NWB LLE, and forgetfulness, experienced multiple falls. EMR review showed that for two of four falls, IDT fall notes documented the circumstances (rolling from bed while repositioning and being found squatting in the bathroom while attempting to get on the toilet) and that assessments, neuro checks, and VS were WNL with no injuries, but did not document whether the resident was asked about or consented to family notification, nor that family was notified. The DON confirmed that the resident was his own decision-maker, that family was notified or present for two of the falls, and that there was no documentation of the resident’s wishes or family notification for the other two falls, contrary to the facility’s “Notification of Changes” policy requiring notification of a resident representative for significant health status changes, including accidents.
The facility failed to maintain complete and accurate EMR documentation for three residents, including one with diabetic foot wounds and Parkinson’s disease, one with a brain injury and severe cognitive impairment, and one with multiple sclerosis. Missing entries included weekly skin assessments, weekly weights, meal intake percentages, and incontinent care on numerous dates, and in some cases incontinent care was recorded only once per day despite residents being always incontinent of bowel and bladder. A CNA reported that agency CNAs often did not complete documentation, and the Administrator and DON acknowledged missing documentation, contrary to the facility’s policy requiring timely and accurate charting each shift.
Surveyors found that the facility did not follow its abuse, neglect, and exploitation policy requiring pre-employment background screening when hiring a CNA. The policy mandates documented background, reference, and credential checks, including DOJ and Governmental Findings reports, before hire. For one CNA, the only DOJ and Governmental Findings reports available were dated the same day the surveyor requested them, well after the CNA’s hire date. The BOM reported being unable to locate any earlier reports or receipts showing that checks had been requested before hire, and the NHA confirmed that no such documentation existed.
An allegation that a cognitively impaired resident with dementia, CKD with heart failure, anxiety, and depression did not receive care from a CNA during a specific shift was reported internally to the NHA but was not reported to the State Agency as required by the facility’s abuse/neglect policy. The policy mandates reporting all alleged violations to the SA and other agencies within defined timeframes, yet the NHA stated the allegation was not reported because it was believed to be a miscommunication issue.
The facility failed to thoroughly investigate an allegation that a CNA did not provide care to a resident with dementia, chronic kidney disease with heart failure, anxiety, and depression, who had severely impaired cognition and an activated POA. The investigation, initiated after an RN’s emailed allegation, consisted of a limited number of summarized staff interviews, one interview with the resident’s POA, and an investigative narrative by the NHA, but did not include interviews with other residents to identify similar concerns or staff education on neglect, and no additional documentation was produced when requested.
A resident with multiple comorbidities and identified risk for pressure ulcers developed a left heel pressure injury that was not comprehensively assessed by nursing staff, was initially misdocumented as being on the right heel, and did not trigger timely updates to the care plan. When the wound care MD ordered more intensive treatment, including Betadine and twice-daily dressing changes, nursing staff failed to transcribe and implement these orders, continuing a less frequent regimen. Comprehensive wound assessments between weekly MD visits were not performed, and facility leadership acknowledged that nurses relied on limited SBAR documentation instead of full assessments. The heel wound progressed to a Stage 4 PI with osteomyelitis and sepsis, and hospital records confirmed a diagnosis of left calcaneal osteomyelitis and Stage 4 heel PI, supporting the finding that the facility did not provide pressure ulcer prevention and treatment consistent with professional standards.
Surveyors found that the facility did not ensure an RN was on duty for at least eight consecutive hours on multiple days, based on PBJ staffing data and review of staff schedules and nurse postings. Interviews with administration revealed that daily staffing postings were created by a receptionist and not manually updated to reflect changes, and that internal schedules, which were not publicly posted, were relied upon instead. Although documentation was later provided to show RN coverage on one of the questioned days and administration reported that corporate RNs rotated to provide coverage, the facility could not produce records confirming eight hours of RN coverage on three specific days, affecting all residents.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation of an alleged abuse incident between two residents, R1 and R2. On 1/4/26 at approximately 2:00 PM, R2, who has a diagnosis of Alzheimer’s dementia, was observed in a common living room area with his hand partially down the top of R1’s pants/brief, moving back and forth, and R1’s shirt partially lifted. R1, who also has dementia, did not appear to be aware of what was happening, and when the witnessing staff member questioned R2, he responded, “what?” The Activities Director (C) immediately separated the residents, repositioned R2’s hand to his own lap, took R1 with her, and reported the incident to the nurse on duty, and law enforcement was contacted. The facility’s written policy, “Freedom from Abuse, Neglect and Exploitation Policy and Procedure,” requires that all reports of abuse be promptly and thoroughly investigated, including immediate protection of residents, initiation of a root cause investigation and analysis, and collection of information to corroborate or disprove the incident. The policy specifies that a thorough investigation must adequately address the circumstances of the allegation, include facts necessary to form a reasoned conclusion, and document involved staff and witness statements, including identifying and interviewing other staff or residents in the immediate area and staff from previous shifts. Despite these requirements, the facility’s investigation of the 1/4/26 incident consisted only of a single written statement from the Activities Director who witnessed and intervened in the event. Surveyor review on 1/29/26 found no evidence that the facility interviewed additional staff or residents who might have witnessed the incident or had knowledge of prior similar behaviors by R2. The Administrator could not state whether any other staff had witnessed the incident or whether other residents were present in the living area at the time. The facility did not determine whether R2 had previously been inappropriate with other peers, whether there were any other sexually related behaviors or statements by R2, or whether any other residents might have been affected. Documentation later submitted by the facility confirmed that any broader staff and resident interviews related to this incident were not conducted until 1/29/26, during or after the survey, rather than at the time of the original event, demonstrating that the facility did not promptly or thoroughly investigate the alleged abuse incident as required by its own policy.
Failure to Report Allegation of Resident Exploitation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of exploitation to the State Agency as required by its abuse, neglect, and exploitation policy. The policy, revised 7/15/22, states that all alleged violations, including exploitation and misappropriation of resident property, must be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. Exploitation is defined in the policy as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. The policy further requires that alleged violations be reported immediately, but not later than two hours if they involve abuse or serious bodily injury, or within 24 hours if they do not, and that results of investigations be reported to government agencies within five working days. The incident involved a resident with diagnoses including anxiety, depression, kidney failure, COPD, and type 2 diabetes, who had intact cognition with a BIMS score of 15 and was their own decision maker. On the evening in question, an agency LPN told the resident they did not have gas money to get home, and the resident gave the LPN eight dollars, which was later returned after another nurse instructed the LPN that accepting money from a resident was unacceptable. The next day, the ADON spoke with the resident, who confirmed giving and then having the money returned, and indicated they knew the LPN from a previous facility and believed their relationship made it acceptable to give money. The ADON reported the incident to the NHA. The NHA acknowledged being informed of the incident, but determined it was not an allegation of exploitation and did not report it to the State Agency, despite the facility’s policy requiring reporting of all alleged violations.
Failure to Thoroughly Investigate Allegation of Resident Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of exploitation involving one resident. The facility’s Abuse, Neglect and Exploitation policy requires immediate and comprehensive investigations of alleged abuse, neglect, or exploitation, including identifying and interviewing all involved persons, witnesses, and others who might have knowledge of the allegation, and focusing on determining whether exploitation occurred. The resident involved had diagnoses including anxiety, depression, kidney failure, COPD, and type 2 diabetes, and had a BIMS score of 15/15, indicating intact cognition and that the resident was their own decision maker. The resident reported that an agency LPN stated they did not have gas money to get home from work and accepted eight dollars from the resident, which was later returned. The resident stated they knew the LPN from a prior facility where the LPN had cared for them and believed their relationship made it acceptable to give the LPN money. The ADON was informed by a nurse that the LPN had accepted money from the resident and had instructed the LPN to return it. The ADON then spoke with the resident, who confirmed giving the LPN gas money and that it had been returned, and stated they felt it was acceptable due to their relationship with the LPN. After this interview, the ADON did not conduct any further investigation. The NHA was informed of the incident and determined it was not an allegation of exploitation, in part because the money was returned and the resident did not appear to have adverse psychosocial effects. The NHA confirmed that no additional residents or staff were interviewed to determine if there were similar concerns or if other residents had been affected, and the facility’s investigation contained no further interviews beyond the resident, despite policy requirements for a complete and thorough investigation of alleged exploitation.
Failure to Document Family Notification After Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to document family notification, or the resident’s wishes regarding such notification, after two of four falls experienced by one resident. The resident was admitted with osteomyelitis of the left foot, diabetic foot ulcers, and Parkinson’s disease, and had a BIMS score of 12/15, indicating moderately impaired cognition. The resident’s fall care plan, initiated due to Parkinson’s disease, weakness, non–weight-bearing status on the left lower extremity, and forgetfulness, identified the resident as being at risk for falls, accidents, and incidents. Despite this, documentation in the EMR did not reflect that the resident was asked whether he wanted his family notified following certain fall events. Review of the EMR showed that on one date the resident reported rolling from bed while repositioning, with no injuries noted, and on another date the resident was found squatting against the bathroom wall while holding onto a bar after attempting to get onto the toilet, with assessment, neuro checks, and vital signs within normal limits and no injuries noted. In both of these IDT fall notes, there was no documentation that the resident was asked if he wanted his family updated about the falls. During interview, the DON confirmed that the resident did not have a POA and was considered his own decision-maker, and that while the son was notified of one fall and the daughter was present for another, staff did not document the resident’s wishes or family notification for the other two falls. This was inconsistent with the facility’s “Notification of Changes” policy, which requires notification of the resident’s representative, if known, for significant changes in health status, including sudden illness or accident, even for mentally competent residents.
Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with its own documentation policy and accepted professional standards. For one resident with diabetic foot wounds, diabetes, and Parkinson’s disease, the EMR showed multiple missing weekly skin assessments over several months, despite the resident having diabetic foot ulcers and being frequently incontinent of bladder and always incontinent of bowel. Weekly weights were also missing on numerous dates from admission through discharge, and meal intake documentation lacked entries on many days, with no indication that meals were served or refused. Incontinent care documentation for this resident was also absent on several dates, and on one date was marked as not applicable due to an indwelling urinary catheter. For a second resident with a brain injury and severe cognitive impairment, the quarterly MDS indicated the resident was always incontinent of bowel and bladder and had no skin issues. However, weekly skin assessments were missing on multiple dates over a four‑month period. In the incontinent care task documentation, there were days within a 14‑day review period where no incontinent care was documented at all, and several days where incontinent care was documented only once per day. These gaps occurred despite the resident’s documented total incontinence status. For a third resident with multiple sclerosis who was cognitively intact and always incontinent of bowel and bladder, incontinent care documentation in the EMR showed numerous days with no incontinent care recorded. Additional days showed incontinent care documented only once on the 7:00 AM to 3:00 PM shift. During interviews, a CNA stated that documentation needed to be accurate but that many agency CNAs might not complete documentation, and the Administrator and DON confirmed there was missing documentation in resident records. The facility’s policy on documentation required that each medical record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation completed at the time of service or by the end of the shift in which care was provided, which was not followed in these cases.
Failure to Complete and Document Pre-Employment Background Check for CNA
Penalty
Summary
The deficiency involves the facility’s failure to implement its Abuse, Neglect and Exploitation policy regarding required pre-employment background screening for one CNA. The written policy, revised 7/15/22, states that potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, and that background, reference, and credential checks will be conducted and documented for potential employees and other specified personnel. During surveyor review on 1/28/26, the facility was asked to provide background check information, including Department of Justice (DOJ) and Governmental Findings reports, for eight staff members. For CNA-C, who was hired on 7/9/25, the DOJ and Governmental Findings reports provided to the surveyor were dated 1/28/26, the same day the surveyor requested them, rather than prior to the hire date. The Business Office Manager reported being unable to locate prior DOJ and Governmental Findings reports for CNA-C and stated that new reports were requested that day. The Business Office Manager believed a thorough background check had been completed by a previous human resources staff member but could not locate the required documentation or any receipt showing that the checks were requested before CNA-C’s hire. The Nursing Home Administrator confirmed that the facility did not have a receipt for DOJ and Governmental Findings reports requested for CNA-C prior to hire and acknowledged awareness that the reports could not be found.
Failure to Report Alleged Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency (SA) as required by its Abuse, Neglect and Exploitation policy. The policy, revised 7/15/22, states that the facility will designate a leadership position responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state Survey Agency and other officials, and that all alleged violations must be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. The policy further specifies that allegations involving abuse or serious bodily injury must be reported immediately but not later than two hours after the allegation is made, and all other reportable events must be reported not later than 24 hours, with final investigation results reported within five working days as required by state agencies. For one sampled resident (R1), an allegation of neglect involving a CNA (CNA-E) on 12/23/25 between 2:00 PM and 9:00 PM was reported internally to the Nursing Home Administrator (NHA-A) but was not reported to the SA. R1 had dementia, chronic kidney disease with heart failure, anxiety, and depression, and a recent MDS dated 12/18/25 showed a BIMS score of 0/15, indicating severely impaired cognition; R1 also had an activated POA. On 1/28/26, the surveyor requested the facility’s report to the SA regarding the allegation that R1 did not receive care from CNA-E during the specified time period and was unable to interview R1 due to cognitive impairment. During an interview on the same day, NHA-A acknowledged not reporting the allegation of neglect to the SA and stated the belief that reporting was unnecessary because the facility had determined the incident was a miscommunication issue.
Failure to Thoroughly Investigate Allegation of Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident and a CNA. The facility’s Abuse, Neglect and Exploitation policy, revised 7/15/22, requires that a designated leader report allegations of abuse or neglect to the state agency and that immediate investigations occur when allegations or suspicions arise. An allegation was made that on 12/23/25, between 2:00 PM and 9:00 PM, a CNA did not provide care to a resident. The resident had dementia, chronic kidney disease with heart failure, anxiety, depression, and a BIMS score of 0/15 indicating severely impaired cognition, and had an activated POA. On 1/28/26, the surveyor reviewed the facility’s investigation, which consisted of an emailed allegation from an RN, four summarized staff interviews, one summarized interview with the resident’s POA, and an investigative narrative written by the NHA. The investigation did not include interviews with additional residents to determine if others had similar concerns and did not include staff education related to neglect. The surveyor was unable to interview the resident due to cognitive impairment. During interview, the NHA stated they believed staff education had been provided and additional residents had been interviewed, but no proof of these actions was provided, and the NHA indicated the facility had determined the incident was a miscommunication issue.
Failure to Prevent and Properly Treat a Heel Pressure Injury Leading to Stage 4 Ulcer and Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury (PI) prevention and treatment consistent with professional standards of practice for one resident, resulting in the development and deterioration of a left heel PI. The resident was admitted after hospitalization for sepsis with multi-organ failure and had multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease stage 3, unspecified dementia, hypertension, and heart failure. The initial care plan identified the resident as at increased risk for pressure ulcer development and included interventions such as a pressure-reducing mattress, administering treatments as ordered, and using barrier creams with each incontinent episode. A comprehensive MDS indicated the resident was at risk for pressure ulcer development, but the surveyor could not obtain documentation of the assessment tool or score used to determine this risk. Subsequently, the resident developed skin integrity issues, including a Stage 3 pressure wound on the right medial buttock that was later resolved. Later, an SBAR form documented a new wound to the heel, described as an open area measuring 8 cm by 5 cm, with a bandage applied and pressure boots placed while in bed. The wound was actually on the left heel, but it was incorrectly documented as the right heel. At that time, there was no comprehensive wound assessment completed that described wound characteristics beyond basic measurements. A treatment order was entered on the TAR for the left heel to cleanse with normal saline, pat dry, apply foam dressing, and secure with Kerlix once daily at bedtime, with daily assessment of drainage, appearance, and surrounding skin. The surveyor could not find evidence of a comprehensive wound assessment for the left heel until a later date. When the wound care physician evaluated the resident, the left heel blister had ruptured and was an open wound with nonviable tissue and necrosis, and debridement was performed. The physician ordered a new treatment plan including Betadine and dressing changes twice daily and as needed, but the TAR was not updated and nursing continued the prior once-daily treatment without Betadine until a later date. The care plan was not updated to reflect the new left heel surgical wound or to include weekly treatment documentation and monitoring until well after the wound had developed. Facility nurses did not complete comprehensive wound assessments upon discovery of the new PI or between weekly physician visits, and the NHA stated the facility does not do comprehensive assessments, relying instead on SBAR forms, of which only one was completed for the new heel PI. Over time, the left heel wound progressed. Subsequent wound care notes documented changes in wound size and treatment modifications, including discontinuation of Betadine and initiation of Hydrofera Blue and other dressings. The resident was hospitalized and later returned with a Stage 4 pressure wound of the left heel, with specific measurements and new treatment orders including Hydrofera Blue, collagen powder, and hypochlorous acid solution. An additional hospital order directed topical Tobramycin Sulfate Injection solution to the left heel twice daily. Later, the resident was again sent to the ER for chills and rigors, with the wound gently packed and the physician noting the resident appeared septic with tachypnea and tachycardia. Hospital records documented sepsis secondary to streptococcus dysgalactiae bacteremia and left calcaneal osteomyelitis, with diagnoses including an open wound and Stage 4 PI of the left heel. The surveyor concluded that the facility failed to implement aggressive interventions to prevent PI development, failed to ensure treatment orders were transcribed and completed as ordered, and failed to complete comprehensive assessments upon discovery and during the course of the left heel PI, leading to an avoidable PI that deteriorated to Stage IV with osteomyelitis requiring hospitalization and IV antibiotics. Interviews with facility leadership confirmed these failures. The DON acknowledged that wound care orders from the wound care physician were not followed, the care plan was not updated, and that the expectation was for nurses to complete and document ordered wound treatments and update the care plan for changes and new interventions. The DON also stated that comprehensive wound assessments were performed by the wound care physician, which explained the lack of comprehensive wound assessment documentation by facility nurses. The NHA, when asked why comprehensive assessments were not completed with the development of the new heel PI and changes in treatment, stated that the facility does not do comprehensive assessments and instead uses SBAR forms for changes in residents, despite only one SBAR being completed for the new heel PI. These documented inactions and omissions formed the basis of the deficiency and the finding of immediate jeopardy.
Removal Plan
- Facility initiated education for all licensed nursing staff (RNs and LPNs) including: prompt identification and reporting of new pressure injuries; completion of comprehensive assessments upon discovery of a new pressure injury; completion of daily diabetic foot checks; accurate transcription, initiation, and completion of physician ordered treatments; implementation of aggressive pressure injury prevention and treatment interventions per standards of practice; education on notification of physician/NP of all new pressure injuries as well as any significant changes to pressure injuries.
- Licensed nursing staff completed competency validation related to pressure injury staging and documentation, treatment application per physician orders, and heel offloading, repositioning, skin protection, and preventive interventions.
- Facility conducted skin assessments and Braden scale assessments of all residents in the facility.
- Facility conducted TAR audits of residents to ensure wound treatments were completed as ordered.
- Facility reviewed resident wound treatment orders to ensure they were accurate and appropriate.
- Facility conducted wound round audits on all residents with wounds/pressure injuries.
Failure to Ensure Required Daily RN Coverage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, as required. Review of the PBJ Staffing Data Report for Quarter 4 of 2025 (July 1–September 30) showed four days within the quarter with no RN hours reported: 08/15/2025, 09/08/2025, 09/09/2025, and 09/14/2025. Further review of the facility’s staff schedules and nurse postings for the last 92 days of that quarter confirmed that on 08/15/2025 (Friday), 09/08/2025 (Monday), and 09/09/2025 (Tuesday), there was no RN scheduled for eight consecutive hours. The facility was unable to provide documentation to support that an RN worked at least eight consecutive hours on those three dates. During interviews on 01/14/2026, the Nursing Home Administrator and Assistant Nursing Home Administrator explained that the receptionist posts the daily staffing sheet in the morning after updating the census, and that the facility does not manually update the public posting to reflect subsequent staffing changes, relying instead on the internal schedule, which is not publicly posted. Later that day, the Assistant Nursing Home Administrator provided documentation supporting RN coverage for 09/14/2025 and stated that corporate RNs had been rotating to provide the required eight hours of RN coverage between 08/15/2025 and 09/14/2025. However, no additional records or documentation could be produced to verify RN coverage for 08/15/2025, 09/08/2025, and 09/09/2025, resulting in a finding that the facility did not ensure RN coverage for at least eight consecutive hours on those dates for all 47 residents.
Some of the Latest Corrective Actions taken by Facilities in Wisconsin
- Implemented education for all licensed nursing staff (RNs and LPNs) on prompt identification and reporting of new pressure injuries; completing comprehensive assessments upon discovery; completing daily diabetic foot checks; accurately transcribing/initiating/completing physician-ordered treatments; implementing aggressive pressure injury prevention and treatment interventions per standards of practice; and notifying the physician/NP of all new pressure injuries and significant changes (J - F0686 - WI)
- Implemented competency validation for licensed nursing staff on pressure injury staging and documentation, treatment application per physician orders, and heel offloading, repositioning, skin protection, and preventive interventions (J - F0686 - WI)
Failure to Prevent and Properly Treat a Heel Pressure Injury Leading to Stage 4 Ulcer and Osteomyelitis
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure injury (PI) prevention and treatment consistent with professional standards of practice for one resident, resulting in the development and deterioration of a left heel PI. The resident was admitted after hospitalization for sepsis with multi-organ failure and had multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease stage 3, unspecified dementia, hypertension, and heart failure. The initial care plan identified the resident as at increased risk for pressure ulcer development and included interventions such as a pressure-reducing mattress, administering treatments as ordered, and using barrier creams with each incontinent episode. A comprehensive MDS indicated the resident was at risk for pressure ulcer development, but the surveyor could not obtain documentation of the assessment tool or score used to determine this risk. Subsequently, the resident developed skin integrity issues, including a Stage 3 pressure wound on the right medial buttock that was later resolved. Later, an SBAR form documented a new wound to the heel, described as an open area measuring 8 cm by 5 cm, with a bandage applied and pressure boots placed while in bed. The wound was actually on the left heel, but it was incorrectly documented as the right heel. At that time, there was no comprehensive wound assessment completed that described wound characteristics beyond basic measurements. A treatment order was entered on the TAR for the left heel to cleanse with normal saline, pat dry, apply foam dressing, and secure with Kerlix once daily at bedtime, with daily assessment of drainage, appearance, and surrounding skin. The surveyor could not find evidence of a comprehensive wound assessment for the left heel until a later date. When the wound care physician evaluated the resident, the left heel blister had ruptured and was an open wound with nonviable tissue and necrosis, and debridement was performed. The physician ordered a new treatment plan including Betadine and dressing changes twice daily and as needed, but the TAR was not updated and nursing continued the prior once-daily treatment without Betadine until a later date. The care plan was not updated to reflect the new left heel surgical wound or to include weekly treatment documentation and monitoring until well after the wound had developed. Facility nurses did not complete comprehensive wound assessments upon discovery of the new PI or between weekly physician visits, and the NHA stated the facility does not do comprehensive assessments, relying instead on SBAR forms, of which only one was completed for the new heel PI. Over time, the left heel wound progressed. Subsequent wound care notes documented changes in wound size and treatment modifications, including discontinuation of Betadine and initiation of Hydrofera Blue and other dressings. The resident was hospitalized and later returned with a Stage 4 pressure wound of the left heel, with specific measurements and new treatment orders including Hydrofera Blue, collagen powder, and hypochlorous acid solution. An additional hospital order directed topical Tobramycin Sulfate Injection solution to the left heel twice daily. Later, the resident was again sent to the ER for chills and rigors, with the wound gently packed and the physician noting the resident appeared septic with tachypnea and tachycardia. Hospital records documented sepsis secondary to streptococcus dysgalactiae bacteremia and left calcaneal osteomyelitis, with diagnoses including an open wound and Stage 4 PI of the left heel. The surveyor concluded that the facility failed to implement aggressive interventions to prevent PI development, failed to ensure treatment orders were transcribed and completed as ordered, and failed to complete comprehensive assessments upon discovery and during the course of the left heel PI, leading to an avoidable PI that deteriorated to Stage IV with osteomyelitis requiring hospitalization and IV antibiotics. Interviews with facility leadership confirmed these failures. The DON acknowledged that wound care orders from the wound care physician were not followed, the care plan was not updated, and that the expectation was for nurses to complete and document ordered wound treatments and update the care plan for changes and new interventions. The DON also stated that comprehensive wound assessments were performed by the wound care physician, which explained the lack of comprehensive wound assessment documentation by facility nurses. The NHA, when asked why comprehensive assessments were not completed with the development of the new heel PI and changes in treatment, stated that the facility does not do comprehensive assessments and instead uses SBAR forms for changes in residents, despite only one SBAR being completed for the new heel PI. These documented inactions and omissions formed the basis of the deficiency and the finding of immediate jeopardy.
Removal Plan
- Facility initiated education for all licensed nursing staff (RNs and LPNs) including: prompt identification and reporting of new pressure injuries; completion of comprehensive assessments upon discovery of a new pressure injury; completion of daily diabetic foot checks; accurate transcription, initiation, and completion of physician ordered treatments; implementation of aggressive pressure injury prevention and treatment interventions per standards of practice; education on notification of physician/NP of all new pressure injuries as well as any significant changes to pressure injuries.
- Licensed nursing staff completed competency validation related to pressure injury staging and documentation, treatment application per physician orders, and heel offloading, repositioning, skin protection, and preventive interventions.
- Facility conducted skin assessments and Braden scale assessments of all residents in the facility.
- Facility conducted TAR audits of residents to ensure wound treatments were completed as ordered.
- Facility reviewed resident wound treatment orders to ensure they were accurate and appropriate.
- Facility conducted wound round audits on all residents with wounds/pressure injuries.
Failure to Provide Required 1:1 Supervision and Safe Positioning During Meals for Aspiration-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision, positioning, and use of assistive devices during meals for a resident with a known history of aspiration. The resident had diagnoses including quadriplegia, dysphagia, expressive aphasia, and anxiety, and required mechanically altered textures and thickened liquids. The resident’s comprehensive care plan, revised in late November, specified 1:1 supervision for all meals, encouragement of small bites and clearing the mouth before the next bite, sealing lips around the cup opening until swallowing was completed, use of a neck pillow for proper neck positioning for all meals, and upright positioning in a wheelchair for meals. The facility’s Dining Experience policy also required individuals to be positioned upright as close to 90 degrees as possible when eating in bed and to receive appropriate cueing and assistance to promote safe swallowing. Prior to the surveyor’s observation, there were documented indications of swallowing and respiratory concerns that were not fully acted upon. On one date in November, a progress note recorded that the resident coughed and had food coming out of the mouth during lunch; staff elevated the head of the bed, assisted with finishing the meal, and provided cues for small bites and clearing the mouth, but the LPN who documented the event did not notify the physician and was unsure if anything further was done. The APNP later stated they had not been notified and would have wanted respiratory assessments at least each shift. In mid-December, the resident reported that their lungs felt funny, had crackles on lung assessment, vomited during the night, and later that day had abnormal vital signs and lung sounds with rhonchi, leading to transfer to the hospital. Hospital records showed the resident was treated for aspiration-related right lower lobe infiltrate and septic shock, and an OT evaluation there reiterated the need for upright positioning, one sip or bite at a time, alternating liquids and solids, and 1:1 supervision during meals. Speech therapy documentation before and after the hospitalization reinforced the need for strict swallowing precautions. A speech therapy progress note in early December indicated the resident required prompting to improve oral containment and bolus management, with safety precautions such as upright posture emphasized to staff. A speech therapy evaluation at the end of December recommended pureed texture, honey-thick liquids, eating in a wheelchair with total supervision, and upright positioning during meals and for at least 30 minutes afterward. A treatment note in mid-January confirmed the resident remained on a pureed diet with honey-thick liquids and required total supervision while upright for meals. A videofluoroscopic swallow study reviewed by the speech therapist showed airway invasion by nectar-thick liquids and poor posture with inability to sense penetration/aspiration. Despite these documented needs and care plan directives, on the morning of January 15 the surveyor observed the resident eating breakfast alone in bed with the head of the bed at approximately 45 degrees and without the prescribed neck pillow. The surveyor heard several deep, congested coughs before the resident’s airway cleared and then observed a large amount of food on the resident’s dignity cover and juice spilling from the right side of the mouth. No staff were present in the room or in the hallway, and the resident indicated that staff had not been in the room to assist or check since breakfast began and that staff did not usually sit in the room to provide supervision during meals. CNAs assigned to the wing reported that they assisted with meal setup and checked on the resident every 15–20 minutes, and the RN confirmed the resident should be directly supervised when eating, as indicated on the Kardex, but also stated the resident typically ate in the room. The DON verified that staff should be with the resident when eating in the room and should watch for signs and symptoms of aspiration. These observations and interviews demonstrated that the facility did not follow its own policy, the resident’s care plan, or therapy recommendations for 1:1 supervision, upright positioning, and use of a neck pillow during meals, leading to a finding of immediate jeopardy beginning on January 15.
Removal Plan
- Reviewed R2's care plan, dietary orders, and ST recommendations and made appropriate updates and revisions.
- Reviewed residents to identify those who require supervision, assistance, cueing, or monitoring during meals due to aspiration risk.
- Educated staff on R2's care plan and supervised meals and snacks for residents at risk for choking or aspiration.
- Instructed nursing staff to verify diet orders and supervision levels prior to serving meals, document the supervision provided, and report swallowing concerns and condition changes.
- Observed meal service to ensure compliance with supervision recommendations.
- Conducted record review and observation audits to ensure ST recommendations are documented in residents' care plans and followed by staff.
Failure to Recognize and Respond to Resident’s Multi‑Day Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to recognize and appropriately respond to a resident’s change in condition over several days following admission after major spinal surgery. The resident was admitted after a C3–C4 laminectomy with diagnoses including cervical spondylosis, diabetes, hypertension, hypothyroidism, atrial fibrillation, and congestive heart failure. On admission, the resident was documented as alert and oriented x4, able to make needs known, with clear lungs on room air and a patent Foley catheter draining clear amber urine. The facility’s policy on change in condition required staff to assess the need for immediate care, provide emergency care as needed, and evaluate the resident, including vital signs, oxygen saturation, blood glucose, and alterations in level of consciousness, and to notify the physician immediately for acute or sudden onset symptoms. Beginning the day after admission, the resident showed multiple documented changes in condition. Progress notes indicated the resident became drowsy and hard of hearing, with the diet downgraded to pureed per the resident’s choice and medications crushed due to swallowing difficulty. On one night, the resident’s oxygen saturation dropped to 79%, improving only to 84% after deep breathing, leading to an order for supplemental oxygen at 2–5 liters, and the resident was placed on 2 liters. Subsequent notes described the resident sleeping throughout a shift, being only alert and oriented x2, spending a lot of time sleeping, and having blood glucose of 45 with involuntary jolting arm movements consistent with hypoglycemia, requiring two doses of 40% glucose gel. A change in condition evaluation documented abnormal vital signs, decreased food and fluid intake, and other changes such as talking less, being tired, weak, confused, and drowsy. Additional notes recorded a slight cough, low blood pressure of 94/52 with an order to hold hydralazine, continued need for 2 liters of oxygen with oxygen saturation at 93%, poor eating, sips of orange juice through the night, and a productive cough with mucus. Despite these ongoing changes, the facility did not initiate and follow through with an appropriate change in condition response. During a care conference, the resident’s family reported concerns about the resident’s eating, confusion, and overall medical condition to the DON. The following morning, when an RN obtained the resident’s vital signs, the blood pressure was 102/53, and the RN attempted to administer medications in pudding but was unable to arouse the resident, who did not drink or open their eyes. The RN left the room and did not return, did not perform a further assessment, did not check the resident’s blood sugar, and did not promptly notify medical staff, despite the family member’s expressed concern that the resident was not eating or drinking and appeared unresponsive. The family member later informed the RN they were going to call 911. When EMS arrived and asked about the resident’s blood sugar, facility staff reported they did not know. EMS found the resident’s blood sugar to be 42, and the resident was subsequently admitted to the hospital with diagnoses including severe hypoglycemia with coma requiring emergent IV glucose administration, sepsis secondary to acute cystitis, depressed Glasgow Coma Scale with decreased responsiveness, and acute kidney injury. The surveyors determined that the facility failed to recognize and appropriately respond to the resident’s change in condition over several days, leading to a finding of immediate jeopardy.
Removal Plan
- Reviewed current residents with like diagnoses to ensure appropriate monitoring and interventions were in place.
- Reviewed residents' progress notes and vital signs to identify residents with a potential change in condition that required provider notification, care plan changes, or additional monitoring.
- Educated licensed nurses on the need to promptly recognize, assess and report a change in condition, including the importance of implementing appropriate follow-up monitoring.
- Educated CNAs on recognizing and reporting changes in condition to a licensed nurse.
- Initiated audits to ensure monitoring protocols are in place for new admissions with diabetes.
- Initiated audits of nursing documentation to ensure changes in condition are promptly identified, pertinent and accurate medical information is communicated to the physician, and appropriate monitoring interventions are implemented.
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