Lafayette Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Darlington, Wisconsin.
- Location
- 719 E Catherine St Box 167, Darlington, Wisconsin 53530
- CMS Provider Number
- 525362
- Inspections on file
- 30
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Lafayette Manor during CMS and state inspections, most recent first.
Two CMAs were found to have access to keys for the locked narcotic box and medication storage room, contrary to facility policy and their job descriptions, which prohibit them from handling or administering narcotics. Both CMAs confirmed they held the keys and participated in narcotic count verifications, while nursing staff and administration confirmed that only nurses are authorized to access and dispense narcotic medications.
Staff failed to immediately report two resident-to-resident altercations, including verbal threats and aggressive behavior, to both the administrator and the State Survey Agency as required by policy. An LPN documented the incidents but only reported one to the administrator, and neither was reported to the State Agency. Both the LPN and administrator later acknowledged that these events should have been reported as allegations of abuse.
Staff failed to investigate documented resident-to-resident altercations involving two residents, despite facility policy requiring immediate investigation of suspected abuse. An LPN recorded incidents where a resident yelled, threw an object, and made threats toward others, but no follow-up investigation was performed.
A resident with a high risk for pressure ulcers did not receive necessary treatment and services, leading to a deficiency in care. The facility failed to implement and document interventions, such as pressure-relieving devices and consistent wound care, resulting in the resident's pressure injury worsening. The lack of communication and coordination among staff, along with an environmental emergency, further contributed to the deficiency.
A resident in hospice care, suffering from serious medical conditions, was subjected to abuse by a CNA who ignored the resident's requests to stop care, causing pain and distress. Despite the presence of other staff, no intervention occurred. The facility's policies on abuse prevention were not effectively implemented, and the incident was not reported to the state agency in a timely manner.
The facility did not adhere to professional standards for food service safety, affecting all residents. Observations included improperly dated food items, a staff member without a hairnet in the kitchen, and a scoop stored inside a sugar container, raising concerns about cross-contamination and infection control.
The facility failed to implement a Quality Assurance and Performance Improvement (QAPI) system, as required by their policy, to identify and address quality deficiencies. The Nursing Home Administrator admitted to conducting only one QAPI meeting since October and confirmed that no Performance Improvement Projects (PIPs) were in place, citing leadership changes as a barrier. This deficiency potentially affects all 39 residents.
The facility's QAA Committee did not include the required members, specifically the Infection Preventionist (IP), in any of the quarterly meetings over the past year. The Nursing Home Administrator was unaware of the IP's required attendance, despite the facility's policy stating otherwise. This deficiency could potentially impact all 39 residents in the facility.
The facility failed to establish an effective infection prevention and control program, with surveyors observing water dripping near residents during meals and a lack of tracking for MDROs. The facility's infection rates were not segregated by type, hindering trend identification. Additionally, the facility lacked a comprehensive water management program, missing key documentation on the building's water system and control measures.
The facility failed to properly label and store medications, as observed in two medication carts and storage rooms. An undated insulin pen, expired morphine tablets, and improperly dated cough syrup were found. Staff interviews revealed inconsistencies in understanding medication expiration protocols, with the DON and NHA acknowledging the responsibility of nurses and pharmacy audits in checking expiration dates.
Two residents experienced issues with weight monitoring and physician notification. One resident had weights recorded using different methods, leading to unclear accuracy, and the physician was not updated on weight changes. Another resident experienced a significant weight loss without physician notification, and there was no documentation of nutritional supplement trials. Interviews revealed inconsistencies in weighing methods and a lack of clear guidelines for notifying physicians about weight changes.
A resident with eczema did not receive a scheduled dose of Dupilumab due to a failure in the facility's pharmaceutical services. The medication was not administered on the scheduled date, and the oversight was not reported or addressed by the staff. The resident's condition worsened, and the issue was not resolved despite being raised by the resident's POAHC.
The facility failed to ensure appropriate use and monitoring of psychotropic medications for two residents. One resident was given Quetiapine without proper diagnosis or monitoring for agitation or aggression, while another resident's care plan lacked documentation on side effects to monitor for their medications. Staff interviews revealed a lack of knowledge about specific side effects, and the facility's policy on psychotropic medication use was not followed.
A resident under hospice care, diagnosed with malignant neoplasm and intracranial hemorrhage, reported pain during care by a CNA who continued despite the resident's request to stop. The facility failed to report the abuse allegation to the State Agency within the required two-hour timeframe, as the report was made several hours later. The Nursing Home Administrator confirmed the delay, acknowledging the breach of the facility's policy on immediate reporting.
A facility failed to thoroughly investigate an abuse allegation involving a resident under hospice care, who reported pain during care by a CNA. The investigation was incomplete, lacking necessary steps such as skin assessments for nonverbal residents and staff education on abuse. Interviews revealed other residents felt unsafe with the CNA, but the facility did not document all conversations or ensure adequate resident protection.
Three residents experienced multiple falls due to inadequate supervision and lack of individualized interventions. A resident with severe cognitive impairment fell without a root cause analysis or new interventions. Another resident with brain cancer and seizures had multiple falls without documented interventions or analysis. A third resident with dementia fell due to a slippery fall mat, with no documented interventions or analysis.
The facility failed to report allegations of abuse and neglect involving three residents. One resident's sexual abuse allegation was not reported to law enforcement, while another's report of rough handling by a CNA was not communicated to the State Agency or law enforcement. Additionally, a resident left unsupervised in the tub was not reported as neglect. Interviews with the Social Service Director and Director of Nursing confirmed these incidents should have been reported.
The facility failed to investigate allegations of abuse and neglect involving two residents. One resident reported rough handling by a CNA, and another reported inattentive supervision during bathing, posing a risk of slipping. Despite these reports, the facility did not conduct necessary investigations or interviews with staff and residents, as acknowledged by the SSD and DON.
Unauthorized Access to Narcotic Keys by Medication Aides
Penalty
Summary
The facility failed to ensure that only authorized staff had access to the keys for the locked narcotic box and medication storage room. Observations showed that two Certified Medication Aides (CMAs) were in possession of the keys to the medication cart and the locked narcotic box, despite facility policy and their job descriptions explicitly stating that CMAs are not permitted to pass or access narcotic medications. Both CMAs confirmed during interviews that they held the keys during their shifts and participated in verifying narcotic counts with the narcotic binder, although they stated they did not administer narcotics to residents. Interviews with nursing staff, including an LPN and an RN, confirmed that only nurses are allowed to dispense narcotic medications. Review of facility policies indicated that the responsibility for the keys to Schedule II medication storage areas lies solely with nurses, and access to these keys should be limited to those who require them. The Administrator and Director of Nursing acknowledged that the CMAs should not have had access to the narcotic box keys, confirming this was contrary to facility policy. No information was provided regarding any specific residents affected or their medical conditions at the time of the deficiency.
Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency as required by facility policy and state law. Specifically, staff documented two resident-to-resident altercations involving two residents, but these incidents were not reported to the State Agency, and one was not reported to the administrator. The facility's abuse prohibition policy requires immediate reporting of such allegations, but this procedure was not followed in these cases. Documentation showed that after supper, one resident exhibited aggressive behaviors, including yelling at another resident and throwing an object in their direction. The same resident also threatened another by slamming her walker into a chair and making a verbal threat. The LPN who documented the events reported only one of the incidents to the administrator and was uncertain about reporting the other. During interviews, both the LPN and the administrator acknowledged that these events should have been reported as allegations of abuse to both the administrator and the State Agency, but this did not occur.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for two of five residents reviewed. Staff documented observations of resident-to-resident altercations involving two residents on the same date, but there was no indication that these incidents were investigated by the facility as required by their abuse prohibition policy. The policy mandates immediate investigation when there is suspicion or report of abuse, neglect, or exploitation. Surveyors reviewed a progress note authored by an LPN, which described an incident where one resident yelled profanities at another, threw a wander guard in the direction of a resident, and later slammed a walker into a chair while making a threatening statement to a different resident. During an interview, the Nursing Home Administrator confirmed that these events should have been investigated as allegations of abuse, but no investigation was conducted.
Deficiency in Pressure Ulcer Care for a Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, leading to a deficiency in care. The resident, who was admitted with a stage 2 pressure injury on her left elbow and had a high risk for pressure ulcer development, did not receive appropriate interventions to manage and heal her pressure injuries. The facility's policy required a care plan with measurable goals and interventions, but these were not effectively implemented or communicated to the staff. The resident's care plan included interventions such as evaluating skin for redness, monitoring ulcer characteristics, and providing wound care per treatment order. However, the facility did not transcribe or carry out orders effectively, and there was no guidance for CNAs on managing the resident's pressure injuries. The resident's nutritional orders included protein supplements for wound healing, but there was no documentation of consistent application of these interventions. Additionally, the facility did not provide a specialty pressure-relieving mattress or any pressure-relieving devices, and the resident's foot was observed directly on the mattress during treatment. The facility's failure to implement and document necessary interventions resulted in the resident's pressure injury worsening, with signs of infection and tunneling. The facility did not document the application of border foam dressing or the Santyl treatment consistently, and there was a lack of communication and coordination among staff regarding the resident's care. The deficiency was further compounded by an environmental emergency that required the transfer of residents to other facilities, during which time the resident's treatments were not documented. The facility's inaction and lack of proper documentation and communication led to the deficiency in pressure ulcer care.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was in pain and discomfort during care provided by CNA D. Despite the resident's repeated requests to stop, CNA D continued with the care, causing the resident to scream in pain. Other staff members, including CNAs and an LPN, were present and overheard the resident's distress but did not intervene to stop the abuse. The resident, who had been admitted to the facility with serious medical conditions including a malignant neoplasm and nontraumatic intracranial hemorrhage, was under hospice care at the time of the incident. The resident had expressed a preference for a male caregiver and had refused care from female staff members, including the administration of medications and changes to his brief. Despite this, CNA D proceeded with the care against the resident's wishes, using dismissive language and ignoring the resident's cries of pain. Interviews with other residents revealed that CNA D had a history of disregarding residents' wishes and making them feel unsafe. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the lack of intervention from other staff members and the failure to educate all staff on abuse prevention following the incident. The facility's response to the incident, including the timing of the report to the state agency, was also inadequate.
Removal Plan
- Care Plan for R40 updated to address pain management: Breathing, Stress Balls during Care, Medications for Pain scheduled instead of PRN
- Discussion between CNA D and Interim NHA A related to resident rights and customer service
- Inservice for all staff on Resident rights/self-determination
- Continue touch bases with R40 to determine if needs are being met
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, potentially affecting all 39 residents. During an inspection, several deficiencies were observed in the kitchen's dry storage and main refrigerator. Unopened pasta bags and canned goods lacked use-by dates, while a container of sunflower seeds was past its use-by date. Additionally, thawed nutritional supplements had no thaw dates, contrary to manufacturer guidelines. Furthermore, a staff member entered the kitchen without a hairnet, and a scoop was improperly stored inside a sugar container, raising concerns about cross-contamination and infection control.
Lack of QAPI System and PIPs in Facility
Penalty
Summary
The facility failed to establish and maintain a Quality Assurance and Performance Improvement (QAPI) system, which is necessary for identifying and addressing quality deficiencies. The facility's policy, dated 1/1/24, mandates the development and implementation of a comprehensive, data-driven QAPI program that focuses on care outcomes and quality of life. However, upon review, there was no evidence of a Performance Improvement Project (PIP) in place to enhance the quality of care for the residents. This deficiency has the potential to affect all 39 residents in the facility. During an interview, the Nursing Home Administrator (NHA) admitted to having conducted only one QAPI meeting since assuming the role in October and acknowledged that the facility was not currently working on any PIPs. The NHA recognized the necessity of having at least one PIP annually to ensure quality care but cited leadership changes as a barrier to prioritizing the QAPI plan and initiatives. The lack of a structured QAPI process and the absence of ongoing PIPs indicate a failure to follow the facility's QAPI plan, which is crucial for identifying and addressing problem areas to ensure resident care quality.
Deficiency in QAA Committee Composition and Meeting Attendance
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required members and did not meet the quarterly meeting requirements. The QAA Committee was supposed to include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members including the Administrator, Owner, or a Board Member, and the Infection Preventionist (IP). However, the review of the QAPI Committee meeting sign-in sheets revealed that the IP was absent from all meetings in the past year, and the Administrator was absent from one meeting. During an interview, the Nursing Home Administrator (NHA) was unaware that the IP needed to attend the QAPI meetings, as infection control topics were presented by the Director of Nursing (DON). The facility's policy, however, clearly stated the requirement for the IP's attendance. This oversight in the composition of the QAA Committee has the potential to affect all 39 residents residing within the facility.
Inadequate Infection Control and Water Management Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by several deficiencies identified during the survey. Surveyors observed missing ceiling tiles with water actively dripping from a pipe into a container near residents during the lunch meal, which posed a potential infection control issue. The Nursing Home Administrator (NHA) acknowledged the situation and agreed that residents should have been seated elsewhere to avoid exposure to the dripping water. Additionally, the facility lacked a mechanism for tracking Multi-Drug Resistant Organisms (MDROs). Although the NHA and the Infection Preventionist (IP) were aware of which residents had MDROs, they did not have a formal tracking system accessible to others. Furthermore, the facility's monthly infection control rates were not segregated by specific infection types, making it difficult to identify trends or increases in certain infections. The NHA admitted that without segregated rates, they could not ascertain increases in specific infection types. The facility also failed to provide evidence of a comprehensive water management program. The surveyor was unable to locate descriptions of the building water system, identification of areas where Legionella and other pathogens could grow, or descriptions of control measures and monitoring processes. The NHA acknowledged that these elements should have been included in the water management program and indicated that they would check with maintenance to locate the necessary documentation.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as observed in two medication carts and two medication storage rooms. On the 2nd floor, an undated open insulin pen for a resident and expired morphine tablets for another resident were found. The 3rd floor medication cart contained a cough syrup with no open or expiration date. Additionally, both the 2nd and 3rd floor medication storage rooms contained expired stock medications, such as Thiamin Vitamin B1, Super View Healthy Eyes vitamins, Paxlovid, and acetaminophen suppositories. Interviews with staff revealed inconsistencies in the understanding of medication expiration and labeling protocols. LPN I indicated that medications were considered good for 30 days after opening, while RN H stated they were good for 28 days. The Director of Nursing acknowledged that insulin pens should be dated upon first use, and the Nursing Home Administrator confirmed that nurses were responsible for checking expiration dates, with the pharmacy conducting audits every three months. However, discrepancies in labeling and storage practices were evident, leading to the observed deficiencies.
Inconsistent Weight Monitoring and Lack of Physician Notification
Penalty
Summary
The facility failed to ensure that two residents, R35 and R17, maintained acceptable parameters of nutritional status. For R35, weights were obtained using different methods, leading to unclear accuracy. The facility did not update R35's physician on weight gain or loss based on these weights. The facility's policy on weight monitoring was not consistently followed, as there was no documentation of re-weights or provider notifications for significant weight changes. Interviews with staff revealed inconsistencies in weighing methods and a lack of clear guidelines for notifying physicians about weight changes. R17 experienced a significant weight loss of 21 pounds, yet the physician was not informed, and there was no documentation of trialing supplements with R17. The facility's dietician noted changes in R17's nutritional supplements, but there was no tracking of supplement consumption or documentation of a trial of Magic Cup supplements. Interviews with the Dietary Manager and Nursing Home Administrator indicated a lack of communication and documentation regarding R17's nutritional interventions and weight changes. The facility's failure to maintain consistent weighing methods and notify physicians of significant weight changes contributed to the deficiency. The lack of documentation and communication regarding nutritional interventions and weight monitoring for both residents highlights a systemic issue in the facility's approach to managing residents' nutritional status. The interim Nursing Home Administrator acknowledged the discrepancies and the need for consistent weighing methods and documentation.
Missed Dupilumab Dose for Resident with Eczema
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R142, by not administering a scheduled dose of Dupilumab, a medication for eczema. The medication was due on 12/6/24, but it was not given, as indicated by the Medication Administration Record (MAR) which showed a circled 'M' and 'N/A' for the administration time. This omission occurred despite the physician's order dated 11/22/24, with a start date of 12/6/24. The resident's Power of Attorney for Health Care (POAHC) reported that the resident's skin condition was worsening due to the missed medication, and the facility had not provided a definitive answer regarding the issue. The facility experienced an environmental emergency, leading to the relocation of residents, including R142, to other local facilities from 11/27/24 to 12/6/24. During this period, medications were sent with the residents to the other facilities. Upon return, the facility staff did not review the MARs to identify missed medications, and the missed dose of Dupilumab was not reported to the Nursing Home Administrator (NHA). The interim NHA, who was previously the Director of Nursing, acknowledged the oversight and confirmed that the missed medication was not documented or addressed appropriately.
Inadequate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for two residents, R17 and R30, during a survey. R17 was administered Quetiapine, an antipsychotic medication, without appropriate diagnoses or indications for its use. The facility's documentation indicated that R17 was taking Quetiapine for depression, but there was no evidence of harmful behavior or appropriate diagnosis to justify the use of this medication. Additionally, the facility was unable to provide documentation that R17 was being monitored for agitation or aggression, which were later added as diagnoses by the physician. R30's care plan and documentation did not specify what side effects of antipsychotic, benzodiazepine, or antidepressive medications should be monitored for, nor was there any documentation indicating that R30's side effects were being monitored by staff. Interviews with various staff members, including CNAs and a Med Tech, revealed a lack of knowledge regarding the specific side effects to monitor for R30's medications. The facility's Nursing Home Administrator acknowledged that specific side effects were not listed in the Medication Administration Record and that staff relied on drug books for reference. The facility's policy on the use of psychotropic medications emphasizes the need for assessing the resident's condition, identifying underlying causes, and evaluating the effects of medications on an ongoing basis. However, the facility did not adhere to these guidelines, as evidenced by the lack of appropriate diagnoses for R17's medication use and the absence of documented monitoring for R30's medication side effects. This failure to follow policy and ensure proper documentation and monitoring contributed to the identified deficiencies.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident, identified as R40, to the State Agency within the required timeframe. The incident occurred at 6:15 AM, and the facility became aware of it shortly thereafter. However, the report to the State Agency was not made until 11:14 AM, exceeding the mandated two-hour reporting window for incidents involving abuse or serious bodily injury. The facility's policy requires immediate reporting of such allegations to the administrator and relevant authorities, but this protocol was not followed in this case. R40, who was admitted to the facility with a diagnosis of malignant neoplasm of the left bronchus or lung and nontraumatic intracranial hemorrhage, was under hospice care at the time of the incident. The alleged abuse involved a CNA who continued to provide care despite the resident's request to stop due to pain. The Nursing Home Administrator acknowledged the delay in reporting to the State Agency and confirmed that the incident should have been reported within two hours, as per the facility's policy.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an accusation of physical abuse involving a resident, identified as R40, who was under hospice care and had a diagnosis of malignant neoplasm of the left bronchus or lung and nontraumatic intracranial hemorrhage. The incident involved a Certified Nursing Assistant (CNA D) who allegedly continued to provide care despite the resident's request to stop, causing the resident to report pain during the care. The facility became aware of the allegation but did not complete a thorough investigation as required by their policy. The facility's policy on abuse, neglect, and exploitation mandates an immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, interviewing all involved parties, and documenting the investigation thoroughly. However, the investigation was incomplete as it did not include all necessary steps, such as conducting skin assessments on nonverbal residents and providing staff education on abuse. The Nursing Home Administrator (NHA A) acknowledged that the investigation was not complete and should have included these additional measures. Interviews conducted by the Social Worker (SW G) revealed that several residents felt their rights were not respected by CNA D, with some expressing that they did not feel safe when CNA D was working. Despite these findings, the facility did not document all conversations with residents, and the measures taken to ensure resident safety were insufficient. The facility's failure to conduct a comprehensive investigation and adequately protect residents from potential abuse constitutes a deficiency in their care practices.
Inadequate Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety to prevent accidents for three residents reviewed for falls. Resident R142, who has severe cognitive impairment and a history of falls, sustained a fall on 11/27/24. The facility did not conduct a root cause analysis or implement new interventions within 72 hours of the fall, as required by their policy. Observations and interviews revealed that the interventions listed in the resident's care plan were not updated following the fall, and staff were unable to locate specific fall interventions in the resident's records. Resident R16, diagnosed with malignant neoplasm of the brain and seizures, experienced multiple falls without significant injuries. Despite being at high risk for falls, the facility did not document any interventions or conduct a root cause analysis for these incidents. The care plan mentioned fall risk precautions, but these were not detailed, and there was no record of Interdisciplinary Team meetings to address the resident's continued falls. Resident R31, who has dementia, also experienced several falls, including one that resulted in a hematoma. The facility did not document any interventions or root cause analysis for these falls. Interviews revealed that the resident tripped over a fall mat, which was noted to be slippery. The facility's failure to document and analyze these incidents, as well as to implement individualized interventions, contributed to the ongoing risk of falls for these residents.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting suspected abuse, neglect, or theft in accordance with section 1150B of the Act. This deficiency was identified in three separate incidents involving residents. In the first case, a resident reported a sexual abuse allegation involving their significant other, which was communicated to the facility by Adult Protective Services (APS). However, the facility did not report this allegation to law enforcement, as required. Interviews with the Social Service Director (SSD) and the Director of Nursing (DON) revealed that both acknowledged the need to report such allegations to law enforcement, but it was not done in this instance. In the second incident, a resident reported that a Certified Nursing Assistant (CNA) was rough with her, but the facility did not report this allegation of abuse to the State Agency or law enforcement. The Social Service Director and the Director of Nursing both recognized that the incident could be considered abuse and should have been reported. In the third case, a resident reported being left unsupervised in the tub by a CNA, which was not reported as neglect to the State Agency. The Social Service Director and the Director of Nursing acknowledged that the lack of supervision could be considered neglect and should have been reported. These failures indicate a lack of adherence to the facility's policy on reporting alleged violations to the appropriate authorities.
Failure to Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to investigate alleged violations of abuse and neglect for two residents. For the first resident, an allegation was made on February 6, 2024, that a CNA was rough with the resident. Despite the resident being unable to identify the specific staff member involved, the facility did not conduct interviews with staff on duty at the time to narrow down the potential perpetrator. Both the Social Services Director (SSD) and the Director of Nursing (DON) acknowledged that the situation should have been investigated as a potential abuse case, and staff should have been interviewed to rule out abuse. For the second resident, an allegation of neglect was made on May 31, 2024, when the resident reported that a CNA was inattentive during bathing, leading to a potential risk of slipping. The CNA admitted to being distracted and not supervising the resident properly. The facility did not conduct an investigation into this incident, despite the acknowledgment from both the SSD and DON that the situation could be considered neglect and warranted an investigation. The failure to interview staff and other residents further contributed to the lack of a thorough investigation.
Latest citations in Wisconsin
Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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