Citations in Wisconsin
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Wisconsin.
Statistics for Wisconsin (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Wisconsin
Surveyors found that multiple residents lived in rooms with significant uncleanliness and disrepair, including soiled items, dust, stains, and broken fixtures. Some residents reported that staff did not clean under beds or repair damaged areas. Facility records did not show evidence of required deep cleaning, and maintenance staff were unaware of needed repairs, despite facility policies requiring regular cleaning and upkeep.
A resident with severe cognitive and physical impairments was physically abused by their cognitively impaired roommate, who was observed by a CNA hitting the resident in the chest. Both residents were unable to recall the incident, and neither sustained injuries. The event occurred despite facility policies requiring protection from abuse.
A resident was found hitting another resident, and while the immediate incident was addressed and documented, the facility failed to interview other staff or residents who might have witnessed the event or had relevant information, as required by policy.
The facility did not address or resolve grievances raised by residents during council meetings over several months. Multiple residents, including those who were cognitively intact and impaired, reported that their concerns about activities, food, and other issues were repeatedly discussed without follow-up or resolution. Staff responsible for handling grievances were not consistently involved in the meetings, and meeting records showed no evidence of timely feedback or action on the issues raised.
A resident with multiple medical and mental health diagnoses was involved in an alleged abuse incident that was witnessed by a CNA but not reported immediately. The incident, involving potential sexual misconduct by another CNA, was only brought to facility leadership's attention weeks later after being discussed among staff. The delay resulted in the administrator and state authorities not being notified within the required timeframe, contrary to facility policy and regulatory requirements.
A facility failed to thoroughly investigate an allegation of sexual misconduct involving a CNA and a resident with severe anemia and mental health diagnoses. The investigation was limited to interviewing only two residents and select staff, with no documentation of staff education or comprehensive skin assessments. The facility did not provide evidence that all necessary steps were taken to prevent further abuse or to ensure a thorough investigation.
A resident admitted with nerve pain and spinal stenosis did not receive scheduled doses of Lyrica for pain management due to medication unavailability and delays in pharmacy delivery. Staff documented the issue and attempted to notify the pharmacy and charge nurse, but the medication was not administered for several scheduled doses. The DON was not informed of the missed doses, and the facility lacked a written policy for acquiring medications when not available.
A resident's legal representative was not granted access to medical records after submitting a written request, even after being named Power of Attorney for Health Care. The facility did not act on the request following the change in the resident's decision-making status, resulting in the records not being released.
Two residents with cognitive impairment were involved in an incident where a CNA failed to immediately report suspected physical abuse by another CNA, resulting in a delay in removing the alleged perpetrator from duty. The facility also did not submit the required five-day follow-up investigation report to the State Agency on time, contrary to policy requirements.
A resident was allowed to self-administer a prescribed nasal spray without a documented assessment or care plan by the IDT or physician, as required by facility policy. Nursing staff left the medication at the bedside and acknowledged the resident's independent use, but there was no supporting documentation in the EMR.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for eight residents, as evidenced by multiple observations of uncleanliness and disrepair in resident rooms and shared spaces. Surveyors observed used urinals, uncovered hampers with soiled clothing emitting strong odors, thick layers of dust on wall heaters and window shelves, sticky floors, candy wrappers, cobwebs, and broken sink drain plugs. Additionally, there were visible stains, splatters, and scrapes on walls and ceilings, missing tiles, and exposed pressed wood in closets. Residents confirmed that staff did not move beds to clean underneath or repair damaged walls, and maintenance staff were unaware of the areas needing repair. The residents affected included individuals with varying levels of cognitive impairment, as indicated by their BIMS scores, ranging from severely impaired to cognitively intact. The observations were confirmed by the Regional Manager of the contracted housekeeping service, who acknowledged staffing shortages and delays in cleaning due to call-offs and weather-related lateness. The facility was unable to provide evidence that deep cleaning had been performed in resident rooms for the month in question, as requested by surveyors. A review of facility policies revealed that daily cleaning procedures required high dusting and disinfection of high-touch surfaces, and the homelike environment policy emphasized providing a safe, clean, and comfortable setting. Despite these policies, the observed conditions did not meet the outlined standards, and the lack of documentation for deep cleaning further demonstrated the facility's failure to ensure a clean and homelike environment for its residents.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and limited physical mobility was not protected from physical abuse by their roommate, who also had cognitive and mobility impairments. The incident took place when a Certified Nursing Assistant (CNA) observed one resident hitting the other in the chest after hearing yelling from the room. The CNA immediately intervened and separated the residents. Both residents were unable to recall the incident or what led to it, and neither sustained injuries as a result of the altercation. The facility's records indicated that both residents had significant cognitive and physical limitations, with one resident having a history of Parkinson's disease, traumatic brain injury, and hemiplegia, and the other also experiencing hemiplegia and cognitive impairment. The facility's policy requires the protection of residents from abuse, neglect, and exploitation, but in this case, a resident was subjected to physical abuse by another resident in their shared living space.
Failure to Interview All Potential Witnesses in Resident-to-Resident Abuse Investigation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. According to the documentation, a certified nurse aide (CNA) heard a resident yelling and discovered another resident hitting him in the chest. The CNA immediately separated the two residents and assessed the victim for injuries, finding none. The incident was documented, and statements were obtained from the CNA and attempts were made to interview both residents involved. However, the investigation did not include interviews with other staff or residents who may have had knowledge of the incident or witnessed similar events. This omission was contrary to the facility's policy, which requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegation. The administrator confirmed that only the CNA was interviewed, as the incident was considered isolated.
Failure to Resolve Resident Council Grievances in a Timely Manner
Penalty
Summary
The facility failed to resolve grievances raised during resident council meetings in a timely manner for three out of six monthly meetings, as evidenced by interviews, record reviews, and policy review. Three residents, including two who were cognitively intact and one who was severely cognitively impaired, confirmed that issues such as requests for more puzzles, shopping trips, fresh fruit and vegetables, snacks, and specific meal preferences were repeatedly brought up in council meetings without follow-up or resolution. Meeting minutes from multiple months showed that concerns were documented but not addressed, and there was no evidence of feedback or updates provided to the council members regarding the status of their grievances. Staff interviews revealed that the Concierge, responsible for addressing grievances, was not invited to several resident council meetings and only recently began attending after being invited by the council president. Residents and council attendees expressed frustration over the lack of follow-up, with complaints remaining unresolved from month to month. The facility's policy requires that council recommendations and issues be reviewed by the Administrator and that responses be presented at the next meeting or sooner, but this process was not followed as documented in the meeting minutes and confirmed by staff and resident interviews.
Failure to Timely Report Alleged Abuse to Administrator and State Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by policy and regulation. Specifically, a staff member witnessed an incident involving potential sexual misconduct by a CNA toward a resident but did not report the incident at the time it occurred. The staff member later communicated the event to another CNA, who then relayed the information to additional staff, resulting in a delay of approximately two to three weeks before the allegation was formally reported to facility leadership. The resident involved had diagnoses including severe anemia, major depressive disorder, and anxiety disorder, and was assessed as cognitively intact. The incident in question was described as the CNA performing a repetitive motion in the resident's genital area under a towel, which was observed by another CNA. The observing CNA did not immediately report the incident due to personal trauma and uncertainty about the reporting process, only coming forward after discussing the event with another staff member. Upon learning of the allegation, the facility removed the accused CNA from the schedule and began an internal investigation. However, the delay in reporting meant that the administrator and state authorities were not notified within the required timeframe. Interviews with facility leadership confirmed that the expectation was for such allegations to be reported to the state within two hours of discovery, which did not occur in this case.
Failure to Thoroughly Investigate and Prevent Further Abuse Following Allegation
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that steps were taken to prevent further abuse for one resident. Upon learning of an allegation of sexual misconduct involving a certified nursing assistant (CNA) and a resident, the facility did not provide evidence that all necessary protective measures were implemented for the affected resident and other residents. The facility's own policy requires immediate protection of the resident, removal from harm, and a thorough investigation, including interviewing all potentially affected residents and relevant staff, as well as documentation of staff education and timely reporting to authorities. The incident involved a resident with severe anemia, major depressive disorder, and anxiety disorder, who was cognitively intact at the time of the event. The allegation was based on a staff report of a rumor regarding potential sexual misconduct by a CNA during a resident's bath. The facility removed the accused CNA from the schedule and interviewed two male residents who could communicate and had received whirlpools from the accused CNA. However, the investigation did not include interviews with all residents or staff from different shifts, and there was no documentation of staff education on abuse reporting. Additionally, the facility did not conduct a comprehensive skin assessment of all residents after the allegation was reported. Interviews with facility leadership confirmed that only staff with direct knowledge of the incident were interviewed, and education on abuse reporting was provided verbally but not documented. The facility did not interview all residents or staff, nor did it complete a house-wide skin assessment following the allegation. The investigation was limited in scope, and the facility failed to provide evidence that all steps were taken to prevent further abuse or to ensure a thorough investigation as required by policy.
Failure to Administer Scheduled Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to administer scheduled medications as ordered for one resident who was admitted with diagnoses of radiculopathy and cervical spinal stenosis. Upon admission, an order was entered for the resident to receive Lyrica 25 mg, two capsules by mouth twice daily for pain management. However, the medication was not administered as scheduled for at least two days following admission, as documented in the Medication Administration Record (MAR) and confirmed by nurse notes indicating the medication was unavailable or pending from the pharmacy. Multiple staff members, including medication aides and nurses, documented the unavailability of the medication and reported attempts to notify the pharmacy and the charge nurse. The resident reported increased pain due to not receiving the prescribed medication and communicated this to a family member. The family member also inquired about the missed doses and was informed by staff that the facility had not received the order from the transferring facility on the day of admission. Documentation and interviews revealed that the pharmacy was contacted, but there were delays in response and delivery, and the resident did not receive the medication for several scheduled doses. Further review showed that the facility did not have a written policy outlining the process for acquiring medications when not immediately available. The Director of Nursing was not notified of the missed doses and stated that she would have intervened had she been aware. The facility's policy required nurses to reorder and ensure an adequate supply of medications, but this process was not effectively followed, resulting in the resident missing multiple doses of a routine pain medication.
Failure to Provide Medical Records to Legal Representative After POA Activation
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's medical records to the resident's legal representative after a written request was made. Initially, the resident was responsible for their own decisions, and the family member's request for records was denied because the Power of Attorney for Health Care (POAHC) had not yet been activated. The facility's policy required a properly executed authorization from the resident or their legal representative for release of records. The family member signed an authorization form, but it was not valid since the resident had not authorized it and was in the hospital at the time. Subsequently, the resident's POAHC was activated, naming the same family member as the legal representative. Despite this change in status, the facility did not revisit or act upon the original request for medical records. Interviews with the POAHC agent and the Nursing Home Administrator confirmed that the request remained unaddressed after the POAHC was activated, and no records were provided to the legal representative. The resident had diagnoses including End Stage Renal Disease, altered mental status, and a stage 4 sacral pressure ulcer at the time of the incident.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that allegations of physical abuse involving two residents were reported immediately and that the required five-day follow-up investigation report was submitted to the State Agency in a timely manner. One resident, who had dementia and severely impaired cognition, and another resident, who had a history of subarachnoid hemorrhage and moderately impaired cognition, were both identified as vulnerable adults in their care plans. The care plans specified that any situation identified as abuse or potential abuse would be reported per facility protocol. On the evening in question, a CNA heard a thud and a resident shouting from behind a closed door while another CNA was providing care, and also overheard a second resident telling the same CNA to stop being rough. The CNA did not report these concerns until her next shift, two days later, stating that there was no one available to report to at the end of her shift and that she was unsure if what she witnessed constituted potential abuse. The delay in reporting meant that the alleged perpetrator continued to work additional shifts before being suspended pending investigation. The facility's initial report to the State Agency was made after the delayed internal report, and the follow-up investigation report was not submitted within the required five-day period. The DON later discovered that the report had not been submitted due to a possible system error or user mistake. The facility's policy required immediate reporting of all alleged violations and completion of the internal investigation within five working days, which was not followed in this instance.
Failure to Assess and Document Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications as required by facility policy. The policy states that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determines the resident has the decision-making capacity to do so safely. Review of the resident's electronic medical record, care plan, assessments, progress notes, and physician orders revealed there was no documented assessment or care plan addressing the resident's ability to self-administer medications. No orders related to self-administration were found, and there was no evidence of an interdisciplinary team meeting or progress note documenting this capability. Despite the lack of assessment and documentation, the resident was observed self-administering a prescribed nasal spray medication in her room, with the medication being left at her bedside for her use. The resident confirmed during interview that she had been self-administering the nasal spray independently for a long time, and nursing staff acknowledged that the medication was routinely left in the resident's room for her to use on her own. The DON stated that such practices should be documented in the assessments, care plan, and IDT meeting notes, but this was not done for this resident.
Some of the Latest Corrective Actions taken by Facilities in Wisconsin
- Updated resident care plans to instruct keeping beds away from heat registers (J - F0689 - WI)
- Re-educated all staff on maintaining safe distances between residents, beds, and heaters (J - F0689 - WI)
- Revised care profiles to require staff verification of safe bed and personal-item placement near heaters (J - F0689 - WI)
- Established ongoing audits of heat-register and room temperatures, with findings reviewed in QAPI (J - F0689 - WI)
- Created a protocol for regular bed-placement audits, assigning the NHA or designee to conduct audits and present results to QAPI (J - F0689 - WI)
- Implemented a Baseboard Heat Registry Protocol mandating safe placement of beds/furniture and prompt reporting of concerns (J - F0689 - WI)
- Changed door and elevator alarm keypad codes to prevent unauthorized clearing of alarms (J - F0689 - WI)
- Directed maintenance staff to rotate alarm codes at defined intervals (J - F0689 - WI)
- Educated staff on the elopement policy, door alarm system, and new code procedures (J - F0689 - WI)
Failure to Prevent Burns Due to Inadequate Monitoring and Unsafe Placement of Baseboard Heaters
Penalty
Summary
Surveyors identified that the facility failed to ensure resident environments were free from accident hazards by not having a system in place to monitor the surface temperature of baseboard heaters and by failing to maintain safe distances between resident beds and these heaters. Multiple residents with impaired mobility and/or cognition were found to have their beds either touching or within a few inches of baseboard heaters, some of which were measured at temperatures significantly above the 125°F threshold considered acceptable for LTC settings. Manufacturer documentation and state guidance both indicated that objects, including beds, should be kept at least 12 inches away from baseboard heaters to prevent burns and other injuries. One resident with severe cognitive and mobility impairments fell out of bed and became trapped between the bed and the wall, coming into prolonged contact with a baseboard heater and sustaining partial thickness (second-degree) burns. This resident had a history of falls, impaired sensation, and required assistance for mobility. The incident occurred when the resident rolled out of bed, and the heater's surface temperature was not being monitored or logged by facility staff. Other residents with similar risk factors were also observed to have beds in direct contact with or very close to baseboard heaters, with measured surface temperatures ranging from 127°F to 169°F. Some residents reported that the heaters were extremely hot to the touch, and staff interviews revealed inconsistent knowledge about required safe distances between beds and heaters. The facility did not have policies or procedures in place to ensure regular monitoring of heater surface temperatures or to ensure that beds and other combustible materials were kept at safe distances from heaters. Staff were not uniformly aware of the risks or the manufacturer's recommendations, and there was no evidence of routine audits or temperature checks prior to the survey. The lack of a systematic approach to identifying and mitigating these hazards resulted in at least one resident sustaining burns and placed other residents at risk for serious harm.
Removal Plan
- Bed was moved away from the heat register for affected resident (R3).
- A larger 42-inch bed was provided to R3 to prevent future falls.
- The baseboard heater in R3's room was replaced with a newer style heater as a precaution.
- R7's bed was moved to the other side of the room away from the heat register.
- Care plans were updated to include instructions to keep beds away from heat registers.
- Re-education of all staff was provided regarding keeping residents and beds away from heaters.
- Ambassador rounds were completed to ensure all beds were moved away from registers.
- Audit of rooms was conducted to check register temperatures with an infrared thermometer.
- All resident rooms were checked and beds closer than 1-2 feet from registers were adjusted.
- Care profiles were updated for staff to check bed/personal item placement in relation to registers.
- All room heat registers had their temperature checked and confirmed to be within manufacturer specifications.
- Rooms were rechecked for bed placement away from registers.
- One resident was moved to another room when their room could not be rearranged to meet safety requirements.
- Audits were created to monitor heat register temperature, room temperature, and corrections for heat registers.
- Audit protocol was created for placement of beds away from registers.
- Random temperature audits of registers to be completed, with all audits reviewed at QAPI.
- NHA or designee to complete bed positioning audits at the same frequency as temperature audits, with review at QAPI.
- QAPI meeting held to review plan, root cause, and ensure compliance with F689.
- Baseboard Heat Registry Protocol implemented: Residents and beds to maintain a safe distance from baseboard heat registers; recliners positioned safely; concerns reported to Maintenance Lead or Administrator for prompt follow-up.
Failure to Supervise and Prevent Elopement for Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent elopement for a resident with severe cognitive impairment and a known risk for wandering. The resident, who had diagnoses including Alzheimer's disease, dementia, PTSD, delirium, and anxiety, was care planned for elopement risk and had a WanderGuard device in place. On the day of the incident, the resident made multiple attempts to exit the unit and was redirected by staff, but no increased supervision was implemented despite the resident's persistent exit-seeking behavior. During a period of high activity with many visitors present, the resident was able to exit the facility through a second-floor stairwell door that was equipped with a functioning alarm. A family member of another resident silenced the alarm and informed staff, who were occupied with other residents and did not follow the facility's elopement procedures. Specifically, staff did not conduct a head count or check the perimeter after being notified of the alarm. As a result, staff were unaware that the resident had left the facility until the police notified them after finding the resident 0.6 miles away in a hospital parking lot, inadequately dressed for the cold weather. Interviews and record reviews revealed that agency staff working that shift had not received orientation or training on the WanderGuard system, and family members had access to alarm codes, allowing them to silence alarms. The facility's investigation was unable to determine exactly how the resident eloped without staff knowledge, but it was clear that staff failed to follow established elopement procedures, including immediate response to alarms, perimeter checks, and head counts. This failure resulted in a finding of immediate jeopardy due to the reasonable likelihood for serious harm.
Removal Plan
- Initiated checks for R1 and updated R1's care plan.
- Changed alarm keypad codes to ensure family members/visitors do not have access to codes or a means to clear alarms.
- Instructed maintenance staff to change the codes at intervals.
- Educated staff on the facility's elopement policy, door alarm system, and new procedure for elevator/door codes.
- Completed elopement drills and tested both systems.
Failure to Protect Resident from Sexual Abuse Due to Inadequate Reporting and Care Planning
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident with a history of inappropriate sexual behavior. One resident, who had diagnoses of metabolic encephalopathy and dementia and was moderately cognitively impaired, had previously attempted to kiss another resident and was reported to have tried to fondle the breasts of a severely cognitively impaired resident. Despite these incidents, the facility did not implement effective preventive measures or update the resident's care plan to address these behaviors until after a subsequent incident occurred. On a later occasion, staff witnessed the same resident with his hand down the pants of the cognitively impaired resident in a common area. Although staff immediately intervened and separated the residents, prior reports of inappropriate behavior had not been communicated to administration or properly documented. Interviews revealed that some staff were aware of previous incidents but did not report them to administration or initiate an investigation, and other staff were unaware of the need to monitor or separate the residents. The care plan for the resident exhibiting inappropriate behavior was not updated to include interventions for these behaviors until after the most recent incident. The facility's failure to report, investigate, and implement preventive measures following initial incidents allowed further abuse to occur. There was a lack of communication among staff and administration regarding the resident's behaviors, and no safety risk evaluation was completed prior to the most recent incident. The facility did not revise the care plan for the victimized resident after the incidents, and not all caregivers were informed of the need for increased monitoring or separation of the residents involved.
Removal Plan
- Completed a root cause analysis to identify failure to report abuse to administration and prevent reoccurrence.
- Assessed each resident and established a care plan and supervision.
- Established systems to monitor and document frequency of behaviors.
- Completed assessments as indicated by psych services.
- Trained facility staff on practices and changes to systems.
- Established a system for auditing and monitoring along with QAPI.
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