FAIR VIEW NURSING AND REHABILITATION CENTER
For profit - Corporation
50 Beds
Independent
Data: November 2025
Trust Grade
70/100
#90 of 321 in WI
Photo by Fair View Nursing & Rehabilitation Center
Photo by Charlie Pattridge
Photo by Fair View Nursing & Rehabilitation Center
1 / 9 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Fair View Nursing and Rehabilitation Center has received a Trust Grade of B, indicating it is a good choice among nursing homes. It ranks #90 out of 321 facilities in Wisconsin, placing it in the top half, and is #2 of 3 in Juneau County, meaning only one nearby facility is rated higher. The facility is improving, having reduced its reported issues from 3 in 2024 to just 1 in 2025. Staffing is a strength, with a rating of 4 out of 5 stars and a turnover rate of 38%, which is below the state average. However, there have been some concerning incidents, including failure to provide necessary treatment for pressure ulcers for some residents and maintaining unsafe food storage practices, which could potentially affect all residents.
- Trust Score
- B
- In Wisconsin
- #90/321
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near Wisconsin's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Wisconsin facilities.
- Skilled Nurses ✓ Good
- Each resident gets 87 minutes of Registered Nurse (RN) attention daily — more than 97% of Wisconsin nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 15 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 28%
Needs review
3 → 1 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Wisconsin average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 38%
Near Wisconsin avg (46%)
Typical for the industry
The Ugly 15 deficiencies on record
1 actual harm
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not promptly notify and consult with a physician when a resident experien...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not promptly notify and consult with a physician when a resident experienced a potential change in condition for 1 of 3 resident's (R1) reviewed for physician notification.R1 experienced consistently low blood pressure while taking Metoprolol (a beta blocker that lowers blood pressure) and the facility did not notify R1's physician.The Mayo Clinic, Cleveland Clinic, John Hopkins, University of Wisconsin Hospital, [NAME] Health, and the American Heart Association (AHA) define hypotension (low blood pressure) as being below 90/60 mm Hg (milliliters of mercury).According to the Mayo Clinic, Complications of C. difficile infection include: loss of fluids, called dehydration. Severe diarrhea can lead to a serious loss of fluids and minerals called electrolytes. This makes it hard for the body to work as it should. It can cause blood pressure to drop so low as to be dangerous.Pathway INTERACT's (Intervention to Reduce Acute Care Transfers) vital signs criteria for clinician notification states a systolic blood pressure (top/first number in blood pressure reading) of less than 90 should trigger clinician notification.The facility's Notification of Changes policy states, Facility must immediately inform the resident; Consult with the resident's provider; and notify, consistent with the resident's activated healthcare power of attorney, the resident guardian when there is: a.) A significant change in the resident's physical, mental, or psychosocial status, b.) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).R1 was admitted to the facility on [DATE] and had diagnoses that included COPD (Chronic Obstructive Pulmonary Disease) requiring continuous oxygen, hypertension (high blood pressure), and a history of C. diff (Clostridium difficile, a bacterium that causes inflammation in the colon). R1's hospital discharge, dated 7/29/25, indicates R1 had a UTI (urinary tract infection) and had discharge diagnoses of hypertension and transient hypotension (low blood pressure). Additionally, upon discharge, R1's blood pressure was 106/50 which was noted as low. Due to this low blood pressure, the hospital discontinued R1's furosemide (diuretic medication) and lisinopril (used to treat high blood pressure) pending a future reevaluation. Upon admission to the facility, R1 was to continue taking her Metoprolol at 50 mg twice daily.Of note, on 7/30/25 at 9:55 AM, it was noted that R1 had experienced 3 watery, foul-smelling stools. This was reported to R1's physician, MD C (Medical Doctor), who then ordered a C. diff stool test, which came back positive.Initial nursing indicate the facility was to gather R1's blood pressure each shift 9 times (3 days, each of the three shifts).On 9/3/25, the facility provided Surveyors R1's historic vitals from her stay at the facility (7/29/25 thru 8/1/25). The heading for blood pressure reads, Blood Pressure (90/60 - 138/88). R1's documented blood pressures:7/29/25 at 10:58 AM: 110/46 (L - low)7/29/25 at 8:00 PM : 86/41 (L)7/30/25 at 6:44 AM: 96/48 (L)7/30/25 at 10:31 PM: 92/48 (L)7/31/25 at 6:33 AM: 81/44 (L)7/31/25 at 1:57 PM: 94/46 (L)8/1/25 at 4:51 AM: 106/89 (H-high)8/1/25 at 11:00 AM: 128/90 (H)It should be noted that the facility's EHR (Electronic Health Records) system flagged the above blood pressures as either high or low. Additionally, R1's Metoprolol was given consistently twice per day and specifically was given on 7/29/25 at 7:15 PM, on 7/30/25 at 7:31 AM and 8:37 PM, on 7/31/25 at 9:13 AM and 8:25 PM, and on 8/1/25 at 8:22 AM.On 8/1/25 at approximately 3:35 PM, R1's blood pressure registered at 52/40. The facility called a rapid response and R1 was taken to the ED (emergency department) where she was found to be septic.On 9/3/25 at 12:18 PM, Surveyor interviewed MD C who stated that she was familiar with R1 and had been trying to manage her blood pressure for years, even as an outpatient before being at the facility. MD C stated that she had not received any notification from the facility regarding R1's low blood pressures but would have expected notification if her systolic blood pressure had dipped below 100. MD C stated that it is hard to say for sure what would have happened if she had been notified but stated that she could have altered R1's medications or could have potentially discontinued her Metoprolol. MD C also stated that R1's C. diff may have contributed to her low blood pressure. MD C stated there is an opportunity to improve communication.On 9/3/25 at 2:23 PM, Surveyor interviewed DON B (Director of Nursing) who stated that the facility did not have any specific blood pressure parameters for R1 but would expect the nurses to use their nursing judgement as to if a blood pressure was too low or high. DON B stated that their facility's parameters for a low blood pressure is 80 systolic and was unaware that the facility's EHR had 90/60 as the low parameters for blood pressure. DON B was unable to find the additional blood pressure readings as part of R1's nursing order for 3 blood pressure recordings daily for 3 days.The facility was aware R1 was experiencing low blood pressure (both systolic and diastolic), continued to administer metoprolol and did not communicate with R1's physician regarding her low blood pressures.
Dec 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 1 of 1...
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Based on interview and record review the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 1 of 1 resident (R10) reviewed for diabetic foot checks.
R10 has no documentation of diabetic foot checks.
This is evidenced by:
Per ADA (American Diabetes Association), dated 2017, foot checks/screens should be conducted daily with a comprehensive exam conducted annually.
Per AMDA (American Medical Director Association), dated 12/9/14, these foot checks/screens are vitally important for treatment of foot problems in patients with diabetes. Common foot problems in diabetic patients are broken down into three categories: at-risk foot, current mild foot/ankle or heel infection or ulcer, and limb-threatening foot/ankle/heel ulcer.
It is important to note that the facility did not have a policy for diabetic foot checks.
Example 1
R10 has a diagnosis of type 2 diabetes mellitus.
R10's medical record was reviewed for documentation of diabetic foot checks.
R10's medical record does not include any documentation of the facility completing daily diabetic foot checks.
On 12/5/24 at 1:44 PM, Surveyor interviewed RN D (Registered Nurse). Surveyor asked RN D what the process is for diabetic foot checks, RN D reported that skin checks were being completed weekly on shower days and that the diabetic foot checks were added to the staff worklist on 12/4/24.
On 12/5/24 at 2:16 PM, Surveyor interviewed ADON C (Assistant Director of Nursing). Surveyor asked ADON C where the documentation regarding diabetic foot checks could be found, ADON C reported that they would be on the worklist. Surveyor requested documentation of diabetic foot checks for R10. ADON C reported to Surveyor that the facility had not been completing daily diabetic foot checks but have been doing weekly skin checks on shower days. Surveyor asked ADON C what the standard of practice is for how often diabetic foot checks should be completed, ADON C stated they should be completed daily.
On 12/5/24 at 3:35 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations were for staff completing diabetic foot checks, DON B stated that they should be done daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents maintain acceptable parameters of nutritional status...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for nutritional status (R29).
R29 experienced a significant weight loss, and the facility did not assess and notify the physician.
Findings include.
The facility's policy on weights states:
*Each resident will be weighed on admission, day after admission and then weekly, unless stated by the physician. Weights will be taken by the certified nursing assistant (CNA) and reported to the team leader who will record them in the residence record.
*If weight changes are identified to be significant, nursing will contact the physician for update and possible recommendations.
The facilities policy titled Nutrition Risk Program, states:
*The registered dietitian, speech pathologist, registered nurse, or other caregiver should identify the resident at nutritional risk during the initial assessment.
* Any member of the healthcare team may alert the nutrition risk team to potential nutritional risk situations i.e., observation of poor intake, weight loss, etc.
*The nutrition risk team will then determine if the resident meets the outline parameters for their nutrition risk program.
*Residents on the nutrition risk program are identified in a few different ways, including a weight loss/gain of 5% or more in the past 30 days or weight loss/gain of 10% or more in the past 180 days. The *Nutrition risk updates will be sent to nursing staff, speech therapy, occupational therapy, physical therapy, and social services as appropriate. The physician will also receive notification that the resident was added to the program.
R29 was admitted to the facility on [DATE] and has diagnosis that include dementia. Her most recent MDS (Minimum Data Set), dated 10/11/24, includes a BIMS score (Brief Interview for Mental Status) of 3, indicating R29 has severe cognitive impairment. R29's MNA (Mini Nutritional Assessment), conducted by the facility on 10/4/24, shows a score of 9, indicating R29 is at risk for malnutrition. R29's care plan states, Problem: Health maintenance .Needs: I report that my appetite is poor. Due to my dementia diagnoses, I am at risk for poor meal initiation .Outcome: Maintain nutritional status .I will maintain current body weight without significant weight change.
The facility documented the following weights for R29:
10/25/24: 178.5 lbs.
10/29/24: 173 lbs.
11/24/24: 168.6 lbs.
11/26/24: 166.4 lbs.
11/29/24: 168.6 lbs.
12/4/24: 169.7 lbs.
On 12/05/24 at 1:31 PM, Surveyor interviewed RD J (Registered Dietician) who stated that CNAs gather weights and the RNs (Registered Nurses) input them into the electronic system. RD J stated that she reviews weights weekly or every couple weeks, but sometimes monthly. RD J stated that if there is a significant change in the resident's weight, it depends on the physician as to who and when they are notified. RD J stated that she had reviewed weights on 11/4/24 and will be putting R29 on the facility's Nutrition at Risk alert for their next meeting on 12/12/24. RD J stated that she had conducted nutritional assessments for R29 on 10/4/24 and 10/18/24 but had not alerted the doctor to any recent weight changes.
On 12/05/24, Surveyor interviewed RN G at 2:45 PM and RN H at 2:39 PM, both of whom stated that CNAs gather weights and report them to them (RN, charge nurse, etc.). Nurses then input the weights. RN G and RN H both stated that they look at the previous weight when documenting weights and if the previous weight is a 5-pound difference, they would request a reweight and if the reweight confirms the original weight, then they would conduct an assessment and notify the resident's physician of weight changes.
It should be noted that no assessments were provided to Surveyors, nor was any evidence provided of correspondence to R29's physician regarding her weight loss. Additionally, no additional weights were gathered between 10/29/24 and 11/24/24 and no evidence was provided of interventions put into place.
On 12/05/24 at 2:02 PM, Surveyor interviewed MD I (Medical Doctor) in person. MD I is also the facility's medical director. MD I stated that he could not recall being notified of R29's weight. While sitting at a computer, MD I searched for any recent contact or correspondence from either facility staff or the Nurse Practitioners (NP) that he oversees and could not see any recent weight notifications. MD I stated R29 was recently visited by an NP on 11/4/29, but there was no mention of weight changes. MD I stated, I did not know. We missed it. I should be much more aware of this and I'm not. MD I also stated that he expects to be notified of any significant weight changes.
R29 experienced a significant weight loss of 6.78% in one month and the facility did not assess R29, notify R29's physician or put any additional nutritional interventions in place. The facility was aware that R29 had lost 5 lbs. between weights on 10/25/24 and 10/29/24 and no interventions or additional weights were gathered between then and 11/29/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure they followed their antibiotic stewardship program that include...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 2 supplemental residents (R11 and R186) reviewed for antibiotic stewardship.
R11 was treated with an antibiotic for an UTI (urinary tract infection) without meeting criteria.
R186 was treated with an antibiotic for an UTI and did not meet criteria.
Evidenced by:
The facility policy, entitled Antimicrobial Stewardship Program, 7/22/24, states, in part: .
POLICY:
A. (Facility Name) has established and will maintain an antimicrobial stewardship program (AMS). AMS programs promote appropriate antibiotic prescribing practices and play a critical role in reducing antibiotic resistance .
C. The Antibiotic Stewardship Team will be responsible for, at a minimum: .
b. Ensuring that (Facility Name) follows the Core Elements of Antibiotic Stewardship as recommended by the CDC (Centers for Disease Control) and required by CMS (Centers for Medicare & Medicaid Services) and the Joint Commission .
f. Defining and tracking metrics specific to antibiotic stewardship.
g. Monitor and report antimicrobial susceptibility trends and communicate these to Healthcare Providers.
h. Reporting outcomes, protocol/practice compliance, and opportunities for
improvement to providers, our administration, and staff. Monitoring of prescribing practices and adherence to policies and protocols and reporting
trends back to the Team and to Healthcare Providers .
Example 1
R11 was admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids).
R11 is listed on the September Infection Control Line List as having a UTI (Urinary Tract Infection). Symptoms are recorded as 9/14/24- right low back pain. Criteria box is marked with an x to show R11 met criteria. Bacteria: Actinotignum schaalii. Antibiotics: Amoxicillin 250 mg (milligrams) BID (twice a day). Start Date: 9/23/24. Stop Date: 9/30/24.
R11's culture dated 9/18/24 shows organism is Actinotignum schaalii with no colony count. R11's culture report dated 9/15/24 shows Organism is gram positive cocci with colony count of 10,000-50,000 CFU (colony forming unit)/mL (Milliliters).
Of note: to meet criteria, the colony count must be 100,000 or over.
R11's Progress Note dated 9/19/24, states, in part: .
Progress Note: A&P (Assessment and Plan) .
(3) UTI: . The latest urine showed gram-positive cocci 10 - 50,000 that appears to be contaminant . Patient denies any dysuria. Is not running a fever and she does have a history of back pain much more likely this is related to musculoskeletal pain .
R11's Physician order, dated 9/23/24, states, in part: . Amoxicillin 250 mg po (by mouth) BID. Total Doses: 14. Clinical Indication: UTI . Order: 9/23/24. Start: 9/23/24. Stop: 9/30/24. Complete: 9/30/24. Complete Reason: Reached Stop Date .
R11's September's MAR (medication administration record) shows R11 received amoxicillin 250 mg x 1 on 9/23/24, bid on 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24 and x 1 on 9/30/24.
Example 2
R186 admitted to the facility on [DATE] and has diagnoses that include Chronic Kidney Disease Stage 3A (a stage of kidney disease where the kidneys are mildly to moderately damaged and are functioning at 45%-59% of what they should be) and Hypertension (defined as blood pressure above 140/90).
R186 is listed on the October Infection Control Line List as having a UTI. Symptoms: strong urine. Type of Infection: UTI. Criteria Met box was left blank. Bacteria: Eschericha coli and Aerococcus species. Antibiotics: Cephalexin 500 mg po BID. Start Date: 10/7/24. Stop Date: 10/10/24.
Of Note: Strong urine is not a symptom of McGeers Criteria.
R186's culture report dated 10/7/24 shows Organism 1 as Escherichia coli with a colony count of >100,000 CFU/mL and Organism 2 as Aerococcus species with a colony count of >100,000 CFU/ML. Sensitivity show cephalexin is susceptible.
R186's Physician Order, dated 10/7/24, states, in part: . Order: Cephalexin 500 mg po BID. Days: 3. Clinical Indication: UTI. Start:10/7/24. Stop: 10/10/24. Complete: 10/10/24. Complete Reason: Reached Stop Date .
R186's MAR shows R186 received cephalexin 500 mg on 10/7/24 x 2, 10/8/24- refused, 10/9/24 R186 received x1 and refused x 1, and on 10/10/24 R186 received x 1.
On 12/05/24, at 10:17AM, Surveyor interviewed IP E (Infection Preventionist), RN F (Registered Nurse) and ADON C (Assistant Director of Nursing). Surveyor asked what standards of practice the facility uses for infection control and IP E indicated McGeers, CDC (Centers of Disease Control) and DHS (Dept. of Health Services). Surveyor asked if R11 met McGeers criteria to treat with an antibiotic for UTI with symptoms of low back pain and colony count of 10,000-50,000 and ADON C indicated no. Surveyor asked if strong urine is a symptom that meets McGeers Criteria and IP E indicated no. Surveyor asked if R186 met criteria to treat with an antibiotic for UTI with symptoms of strong urine and Escherichia coli with a colony count of >100,000 CFU/mL and Aerococcus species with a colony count of >100,000 CFU/ML. IP E indicated R186 had increased incontinence but was unable to provide supporting documentation. ADON C and IP E indicated R186 did not meet criteria to treat UTI with antibiotics.
Oct 2023
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2
R21 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, anxiety disorder, pos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2
R21 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, anxiety disorder, post- traumatic stress disorder, and dissociative identity disorder.
Surveyor requested monthly pharmacy reviews for R21. The facility was unable to provide any documentation that R21's medications had been reviewed by a pharmacist since 1/23/23.
On 10/5/23 at 11:00 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she was able to find any monthly pharmacy reviews for R21 since 1/23/23, NHA A stated no, that was the last one and that she spoke with the pharmacist, and he is working on them today.
Based on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 2 of 5 residents reviewed for unnecessary medications (R33 & R21).
R33 did not have a monthly medication review conducted by a pharmacist.
R21 did not have a monthly medication review conducted by a pharmacist.
Findings include
The facility's Consultant Pharmacist policy states, The pharmacist/contracted pharmacy is responsible for conducting a monthly review of all patients' medication regimens. This review must include a review of the resident's medical chart .The pharmacist must report any irregularities to the attending physician and the facilty's medical director and director of nursing, and these reports must be acted upon.
R33 was admitted to the facility on [DATE].
Surveyors requested monthly pharmacy reviews for R33 and the facility was unable to provide any documentation that R33's medications and medical chart had been reviewed by a pharmacist since 7/19/23 when a pharmacist documented on R33's IV antibiotic in relation to aspiration pneumonia.
On 10/5/23 at 10:18 AM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A confirmed R33 had not had a monthly medication review and also stated that the facility was behind on monthly medication reviews and that facility would conduct an audit to find which resident's medications needed reviewing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the resident's medical record does not include documentation the resident e...
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Based on record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and pneumococcal immunization for 1 of 5 residents (R25) reviewed for immunizations.
R25 did not receive the pneumococcal vaccine.
This is evidenced by:
The facility's policy titled Pneumovax Vaccine, no date, states in part: A. On admission to LTC (Long Term Care) and with a MD (Medical Doctor) order, pneumovax vaccine will be encouraged for all resident who have not previously received this vaccine .2. Each resident or resident's legal representative receives education regarding the benefits and potential side effects of immunization .5. Refusal of vaccine will be documented in the resident's medical record. 6. Revaccination will be based on current CDC (Centers for Disease Control) .
R25's medical record has no evidence or documentation to show that R25 or their representative was provided education, risks vs. benefits, or side effects regarding the pneumococcal vaccination in order to make an informed choice about receiving/declining the pneumococcal vaccination. There is no evidence of R25 declining the pneumococcal vaccination.
On 10/4/23 at 3:13 PM, Surveyor interviewed RN F (Registered Nurse); RN F is also the facility's Infection Preventionist. Surveyor asked RN F if she reviewed R25 for his eligibility for an updated pneumonia vaccine, RN F reviewed her vaccination log and stated that they must have missed him. Surveyor reported to RN F that according to the CDC's (Center for Disease Control and Prevention) PneumoRecs VaxAdvisor, R25's recommendation is for him to receive one dose of PCV20 at least 1 year after PCV13 .or give one dose of PPSV23 at least one year after PCV13, RN F stated that she would look into it.
On 10/5/23 at 8:34 AM, Surveyor interviewed MD G (Medical Director). Surveyor asked MD G if he would have expected that R25 would have received an updated pneumonia vaccination, MD G stated that R25 is diabetic, so he would qualify and that he is at an increased risk for pneumonia.
R25 did not receive the pneumonia vaccine per the CDC recommended schedule for vaccinations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 1 of 5 sampled residents (R14) and 3 of 3 supplemental residents (R10, R15, R18) receiving an anticoagulant medication.
The facility did not develop a Care Plan for precautions or monitoring related to use of anticoagulation medication for R10, R15, R14 and R18.
Evidenced by:
(It is important to note the facility did not have a policy related to the use of anticoagulants.)
The facility policy, entitled Multidisciplinary Plan of Care, undated, includes, in part: The multidisciplinary plan of care is developed as soon as possible after the resident is admitted . A basic care plan is developed within 48 hours by the Interdisciplinary Team. A comprehensive care is then developed no later than one week after the completion of the comprehensive assessments (within 21 days after admission) . plan of care includes the following: identified resident needs, identified resident goals which are realistic and described in terms that are measurable , related to a reasonable achievement time, or maintenance of highest functional level . approach to meeting identified goals, include care of services that must be provided to meet these goals . frequency of service .
Example 1:
R10 was admitted to the facility, on 10/11/22, with diagnoses including: Arteriovenous fistula (an abnormal connection between an artery and a vein), presence of prosthetic heart valve, presence of coronary angioplasty implant and graft, peripheral vascular disease, Hypertension (high blood pressure), Atherosclerotic heart disease of native coronary, hypokalemia (low potassium), and paroxysmal atrial fibrillation (irregular heart rhythm).
R10's Physician Orders, for 10/2023, include: Warfarin Sodium (Coumadin) . 5 mg (milligrams) . by mouth daily .
Review of R10's care plan and CNA (Certified Nursing Assistant) Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Warfarin), such as special precautions and monitoring for/or reporting unusual bruising or bleeding.
Example 2:
R15 was admitted to the facility, on 2/7/22, with diagnoses including: Chronic pulmonary embolism (one of the pulmonary arteries in the lungs gets blocked by a blood clot), long term use of anticoagulants (blood thinner), and venous insufficiency (blood pools in the veins).
R15 Physician Orders, 10/2023, include: Apixiban (Eliquis) 5mg (milligrams) by mouth daily .
Review of R15's care plan and CNA Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Apixiban), such as special precautions and monitoring for/or reporting unusual bruising or bleeding.
Example 3:
R14 was admitted to the facility on [DATE]. Her diagnoses, include: paroxysmal atrial fibrillation (irregular heart rhythm), hypokalemia (low potassium), and combined systolic and diastolic congestive heart failure (reduced heart pumping ability).
R14's Physician Orders, 10/2023, include: Apixaban (Eliquis) 2.5mg (milligrams) by mouth daily .
Review of R14's care plan and CNA Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Apixiban), such as special precautions and monitoring for/or reporting unusual bruising or bleeding.
Example 4:
R18 was admitted to the facility on [DATE] with diagnoses, including: chronic atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), and nonrheumatic aortic (valve) stenosis (narrowing of the valve).
R18's Physician Orders, 10/2023, include: Warfarin Sodium 3mg (milligrams) by mouth Sunday, Tuesday, Thursday, Saturday . Warfarin 2.5mg by mouth Monday, Wednesday, Friday .
Review of R18's care plan and CNA Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Warfarin), such as special precautions and monitoring for/or reporting unusual bruising or bleeding.
On 10/5/23 at 9:12 AM Unit Coordinator E indicated the facility does not have interventions, goals, or a monitoring system for residents on anticoagulant medications, but they should have.
On 10/5/23 at 9:23 AM RN D (Registered Nurse) indicated the facility does not have anticoagulant care plans or a plan for monitoring residents receiving anticoagulant medications.
On 10/5/23 at 9:30 AM DON B (Director of Nursing) indicated there should be a anticoagulant care plan to identify residents at risk for bruising and bleeding and a place for nurses to monitor.
On 10/5/23 at 9:39 AM ADON C (Assistant Director of Nursing) indicated R14, R10, R15, and R18 should have goals and interventions related to bruising and/or bleeding due to their use of anticoagulant medications.
On 10/05/23 at 12:06 PM RN F stated, I will be adding to R15's, R14's, R10's, and R18's care plan to include goals and interventions related to anticoagulant use/monitoring.
R10, R14, R15, R18 were without a care plan to monitor for bruising/bleeding and what interventions should be implemented while receiving an anticoagulant (blood thinner).
Jul 2022
8 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives nec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, prevent new ulcers from developing, and a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable in 2 of 3 residents reviewed for pressure injury concerns (R27 and R31) out of a total sample of 14.
R27 was at risk for pressure ulcer development due to her diagnoses and health history patterns. The facility was aware and failed to prevent pressure injuries from developing, failed to monitor R27's wounds by measuring weekly per current standards of practice, failed to implement interventions to protect R27's right lower extremity from further injuries.
Surveyor observed wound care performed with R31 using poor hand hygiene practices.
Evidenced by:
AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer [Injury] is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear.Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications.Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission, .Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment.Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer.Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the periwound skin .including type and amount of drainage.Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer .
The National Pressure Ulcer Advisory Panel (NPUAP) at www.NPUAP.com defines PI's (Pressure Injuries) in the following categories:
Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.
Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.
Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown.
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.
Suspected Deep Tissue Injury - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
Manufacturer's recommendations for use of the Comfy Splints Multi Podus Boots, dated 2016, include, in part: . Comfy ambulation boot . for use with minimal to moderate ambulation and transferring . upon order of a physician .
Example 1
R27 was admitted to the facility on [DATE] with diagnoses, including CMT (Charcot-[NAME] Tooth disease), Neuropathy, and Amputation of left lower extremity below knee. CMT is a spectrum of nerve disorders that damage the nerves in the arms and legs.
R27's MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/3/21 indicates R27 is at risk for PI (pressure injury) development and her skin is intact. R27's MDS with ARD of 2/17/22 indicates R27 is at risk for PI development, and she has 2 stage 3 PI, no venous or arterial injuries, and infection of the foot. R27's MDS with ARD of 5/17/22 indicates R27 is at risk for PI development, and she has 2 stage 3 PI, no arterial or venous injuries, and infection of the foot.
R27's Comprehensive Care Plan, initiated 10/5/21, includes: start 12/3/21 problem: PI of right foot, heredity of motor and sensory neuropathy . transfer me with use of EZ stand and one assist . alternating air flow mattress on bed . pressure redistribution cushion in my wheelchair . encourage me to keep my right foot elevated when I am in my wheelchair, honor my choice to decline . float my heel in bed . use protective boot when I am up in my chair . I require increased protein needs due to wound healing from ulcerations to the right foot . I report times of feeling depressed that I still have not reached my goal of returning home at this time and further infection concerns with my other leg.
R27's Medical Record contained the following:
12/6/21 NN (Nurse Note): Resident was found with small pressure areas to her right foot from the use of her new walking shoe. She has 5 areas. Right lateral ankle 0.5cm x 0.5 cm x < 0.1 cm wound bed is dry with light eschar.
Right medial foot 0.5cm x 0.5 cm x < 0.1 cm wound bed is dry with light eschar
Toes 3rd, 4th, 5th mid phalanges 0.3 cm round white areas to all.
R27 had worn her shoes this weekend for transfers, and she has no feeling in her feet. She has diagnosis of hereditary motor and sensory neuropathy. Staff will not place regular shoe on her foot for transfers but will place the Darco boot which is soft with Velcro straps. MD updated and new orders received to dab betadine every other day (48 hours) total 5 times.
(It is important to note there is no mention of shoes not to be used in R27's Comprehensive Care Plan.)
12/6/22 NN R27's MD was here this afternoon and looked at the sores on R27's right foot. Agreeable to the treatment of betadine to sores every other day. Also ordered a consult with podiatry for molding a shoe for the right foot. Sores are dry with no redness .
12/7/22 NN R27 is sitting up in her wheelchair at this time. She had surgical shoe on and informed her that because of the sores on her right foot, MD does not want her wearing any shoes at this time. This writer removed surgical shoe and gripper sock. Area to top of right foot, 3/4/5 toes, and ankle are scabbed and dry .
(It is important to note R27 is wearing her shoe again and the intervention is not in R27's Care Plan. It is also important to note there is no wound measurements found from 12/7 to 12/22.)
12/22/21 NN all wounds measured and assessed to right foot.
Right lateral ankle measures 0.5cm x 0.8cm with a dry scab, peri wound very light pink
Right medial foot measures 0.8cm x 0.9cm with dry scab, peri wound very light pink
3rd digit of right foot measures 1cm x 0.6cm and this is dry, but no scab
4th and 5th digit right foot measures 0.3cm x 0.3cm and these areas are dry
. the medial foot and ankle have increased in size. They appear more superficial, and the scabs will fall off with probable healthy tissue underneath . Per MD staff is not to put any shoes on and staff is using gripper socks only which alleviate any pressure .
(It is important to note there are no wound measurements found in R27's record from 12/22/21 to 1/12/22)
1/12/22 MD Progress Note: R27 presents from facility with chief complaint of ulcerations on the dorsum of the foot and toes. She is here with her daughter . She comes with a very soiled dressing and states that they have not been doing much for it. Exam: Ulcerations noted to the dorsum of the digital areas on her foot. She has had below the knee amputation of the left lower extremity secondary to ulcer similar-to what she has in the right foot at this time. Also, over the medial cuneiform there is a full thickness ulcer measuring approximately 0.5cm in diameter with necrosis. Surgical debridement elicits some granulation and bleeding. Also, a lesion on the lateral aspect of the right foot measuring approximately 0.5cm in diameter. This too is full thickness, but no probing to bone . At this time, I cleansed all wounds with wound cleanser and applied Silvadene and sterile dressing. I put in orders for a Rooke boot as well as wound care. R27 is allergic to Silvadene so I switched it to Bactroban ointment to be applied twice daily after wound care cleansing and sterile dressings. I also placed R27 on doxycycline 100 mg twice daily for 10 days . Follow up in one-week right foot .
1/12/22 NN R27 saw MD . in regard to the ulcers on her right toes and foot. Order received to apply Silvadene to ulcers on right foot and cover. Silvadene was changed to mupirocin due to sulfa allergy, was started on doxycycline twice daily.
1/13/22 NN R27's foot continues to be red, and wounds appear infected. Betadine and mupirocin applied. Kerlix, stockinette, and a green foam boot to finish the dressing process. She tolerated well .
1/13/22 NN R27's foot is less red, wounds appear about the same. Old dressing moist with moderate serous drainage .
1/14/22 NN .Foot and lower leg were not red or warm to touch .
1/19/22 MD Progress Note: R27 presents in wheelchair for re-evaluation of right foot ulcerations. I had seen her a week ago and placed her on cleansing of the wounds with utilization of Bactroban ointment. She is also on doxycycline 100mg twice daily. She also has a protective boot which is soaked from the dressings that are soaked also . Exam: Drainage of the lesions are noted primarily in the midfoot area over the hammertoes 2 through 5 regions. There is no cellulitis but again drainage is noted . She has advanced neuropathy . At this time, I cleansed the wounds with wound cleanser and applied Aquacel Silver to the site and follow this with sterile 4x4s and a Kling dressing. I wrote orders for the staff to do the same. I will re-evaluate . in 1 week .
1/26/22 MD Progress Note: R27 presents for re-evaluation of ulcerations on her right lower extremity primarily on the dorsum of her right foot. She had similar lesions previously on her left lower extremity before her below the knee amputation. She is very concerned about losing her right lower extremity at this point. Active problems: Neuropathy, open wound of right foot, pressure ulcer of toe of right foot, pressure ulcer of dorsum of right foot, amputation of left lower extremity below the knee . Exam: Drainage noted from her dressing with yellow discoloration and sloughing on the dorsum of her right foot. There is a slight odor with erythema localized to the foot itself. There are open sores with lesions, but no sinus tracts noted. Prominent areas on the cuneiforms and lateral ankle show necrotic tissue with ulcerations measuring approximately 0.5cm in diameter. At this time, I cleansed the wounds with wound cleanser and debrided all necrotic and slough tissue. I took a culture interdigitally to be sent for culture and sensitivity. I applied Aquacel Silver to the wounds and follow this with sterile 4x4's and Kerlix dressing. Orders were written for the nursing home to do this treatment twice daily applying Aquacel Silver and sterile dressings. I placed R27 on doxycycline 100mg twice daily for 14 days. Re-evaluate in one week .
(It is important to note the facility is not measuring R27's wounds weekly and this is the first measurement recorded since 1/12/22).
1/27/22 NN R27 started on doxycycline for foot infection.
1/28/22 R27 has been taking doxycycline 100mg twice daily and will be starting on ciprofloxacin 500mg twice daily . this evening due to the results from wound culture . Her right foot is reddened and has open areas treated with Aquacel AG with twice daily dressing changes .
1/30/22 NN R27 is resting in bed . No adverse side effects noted from doxycycline or cipro which she is receiving for wounds . Dressing . is clean dry and intact and green PR boot is on . continues with slough tissue on inner ankle area . Remains on Cipro 500mg twice daily and Doxycycline 100mg twice daily for pseudomonas in right leg wound .
2/2/22 MD Progress Note: R27 presents for re-evaluation of ulcerations on the dorsum of her foot. Exam: Removal of dressing reveal minimal erythema and a lot less drainage from last week. Again, the second digit shows an ulceration interdigitally also . I cleansed the wounds and applied Aquacel Silver, Adaptic Sterile 4x4s, and a kerlix dressing. I wrote orders for the nursing staff to continue cleansing twice daily with warm soapy water, applying the Aquacel silver and sterile dressings.
2/8/22 NN: All wounds measured and assessed to right foot.
Second digit: 2.2cm x 1.5cm depth undetermined. The wound bed appeared to have small amount of dry yellow slough and pinpoints of granulation tissue. Margins irregular and peri wound pink in color. This wound bed is translucent skin over wound. The other digits have no open areas, . remain very fragile.
Dorsum of right foot medial aspect: 1.5cm x 1.6cm x depth undetermined due to thin translucent skin over wound. Margins are regular and noted boney prominent wound bed. No drainage noted.
Dorsum of right foot lateral aspect: 1.5cm x 1.8cm x <0.1cm. No drainage noted, but skin is very fragile. Peri-wound is also pink.
Lateral aspect of right lower leg: 1.2cm x 0.7cm x undetermined. The wound bed has a thin translucent skin over wound. Wound bed shows ½ dry yellow slough and pinpoints of granulation.
The right lower leg is all over fragile . heel appeared spongy when palpated . Resident will wear the green boot to alleviate pressure and protect. While in bed the green boot is removed and foot elevated with a chucks when wounds drain . MD aware.
(It is important to note the facility is not measuring the wounds weekly and these are the first measurements recorded by MD or nursing staff since 1/26/22).
2/9/22 MD Progress Note: Exam: sloughing and drainage noted on the dorsum of right foot. She has severe contractures of hammertoes and skin slough in these areas. She has a prominent quarter size ulceration on the dorsum of her medial cuneiforms (three bones of midfoot) over the exostosis (bone overgrowth) region. There is no sinus tract no purulent drainage noted . I ordered antibiotics of right lower extremities.
2/9/22 NN: R27 started on Arithromax 500 mg daily for 5 days (antibiotic) . already on doxycycline . MD discontinued Doxycycline and started Arithromax . Dressing changed to right foot as dressing was wet with yellow drainage .
2/11/22 NN: . continues to have moderate amount of serosanguineous and yellow colored drainage. Soft green boot in place.
2/12/22 NN: . small amount of yellow drainage. Soft green boot in place.
2/13/22 NN: . right leg continues to have some redness, no increased warmth. R27 has no feeling in her right leg .no drainage noted .
2/15/22 MD Progress Note: R27 presents for re-evaluation of cellulitis in ulcerations on her right lower extremity. Exam: Ulcerations noted on the dorsum of the right foot as well as over the medial cuneiform quarter size lesion, on the anterior aspects of right lower extremity, and on the medial malleoli region (ankle). The drainage is less than last week with some necrotic areas. No gangrenous changes noted . At this time, I cleansed the wounds with wound cleanser and applied aquacel silver, Adaptic, sterile 4x4s and a kling compression dressing. Orders were written for nursing staff to continue with the wound care as directed twice daily. She will continue Cipro as directed. Her ABIs (arterial brachial index- a measure of blood flow to the lower extremities) on the right lower extremity came back normal .
2/17/22 NN: R27 had labs drawn today. MD concerned her with her sed rate as it was 75 which is very high (sign of inflammation) . concerned that the oral antibiotics are not working for the cellulitis in her right foot. Order received for Vancomycin one time loading dose of 1750mg tonight and then 1250mg twice daily for two weeks . then he will re-evaluate . placed a midline in her antecubital .
2/17/22 MD Progress Note: . Reports new lesion . multiple open wounds right dorsum/lateral malleolus and toes dorsum . and right foot continue Cipro . MRI (Magnetic Resonance Imaging-type of x-ray) of right foot side and ankle, IV (intravenous) Vancomycin .CBC, ESR, CRP, procalcitonin, CMP also to be ordered .(labs used to detect infection)
(It is important to note the facility did not provide measurements related to the open sore on knee and has not recorded any measurements since 2/8/22.)
2/19/22 NN: . has open areas from just above the ankle to toes. Due to having high Vancomycin trough, (lab to monitor kidney function while receiving vancomycin) her IV for this morning and evening were ordered to be held . moderate amount of sanguineous drainage to prior dressing noted . [NAME] soft boot applied afterward to protect foot .
2/23/22 MD Progress Note: R27 presents for evaluation cellulitis to the right lower extremity. She has been undergoing IV . but today . IV line failed . Ulcerations noted on the dorsum of her right foot as well as on the midfoot region quarter size legion as well as on the medial malleolus . slight drainage with erythema up her leg .
2/23/22 NN: midline in left upper arm was pulled due to not flushing and was halfway out .
3/3/22 MD Progress Note: 1 right mid pretibial ulcer into dermis .2 top of right foot ulcer continues-less red but over bony prominence dorsum foot .3 right lateral malleolus opening red . 4 toes of the 2nd, 3rd,4th digits opening into dermis or extensor toes over prominences .
3/7/22 NN: X ray to right foot shows no osteomyelitis . Pharmacy recommendation discussion of next course of action for open areas on right foot and use of long-term antibiotics .
3/8/22 MD Progress Note: MRI ordered .x-rays are negative for osteomyelitis, but MRI is gold standard and need to be ordered to confirm osteomyelitis is not present.
3/9/22 MD Progress Note: . looks a lot better with less erythema in her right lower extremity and no increased temperature. She still has some ulcerations in the midfoot area as well as on the anterior tibial region . I cleansed wounds with wound cleanser and applied Bactroban and sterile dressings .orders for nursing home . discussed antibiotic use with Pharmacist . continue Vanco IV as directed .
3/10/22 NN: Second digit 0.6cm x 0.9cm x depth undetermined. There are some areas that are covered with scab and slough. Area is often moist; skin is translucent over wound. The other digits have no open areas but remain fragile and moist.
Dorsum of right foot medial aspect 1.2cm x 1.4 cm x depth undetermined due to thin translucent skin over wound. Margins are regular and noted boney prominent wound bed. No drainage noted.
Dorsum of right foot lateral aspect 1.4cm x 0.8cm x depth undetermined. No drainage noted, scab over wound bed. Skin is fragile.
Lateral aspect of right lower leg 0.7cm x 0.2cm x 0.1cm. The wound bed has a thin translucent skin over wound. Wound bed shows yellow slough and is weeping.
Skin to right lower extremity is all over fragile and has potential for further skin breakdown. There are areas that are dry and crusty . Areas are cleaned with saline and Mupirocin was applied . Resident has her green boot on to alleviate pressure and protect when she is up .
(It is important to note these are the first recorded measurements by MD or nursing staff since 2/8/22.)
3/10/22 NN: Dressing to right foot saturated and continues to drain .
3/13/22 MD Progress Note: .daughter unable to take R27 home due to her level of care . multiple wounds right leg that are poorly healing but less red less swollen and has an increased risk of poor healing and bony infection.
3/16/22 MD Progress Note: MRI of the right ankle shows early osteomyelitis despite IV Vancomycin and despite oral Cipro given for MRSA (Methicillin Resistant Staph Aureus) and Pseudomonas (bacteria in wound) . there is a good chance R27 may have to have an amputation of her right leg . if does not show improvement . Ulceration noted again on the dorsum with hammering of the digits 2 through 5 on the right foot. Erythema is subsided as well as edema. There is no pungent odor. Review of MRI shows possible suspect osteomyelitis to the lateral fibula. At this point there is no ulceration to this area and only small eschar which is healed. She has an ulcer primarily quarter size on the dorsal of the medial cuneiform. There is no bone exposure. I cleansed the wounds . aquacel silver . I do not feel the MRI warrants any bone biopsy at this point .
3/16/22 NN: MD was here today and reviewed MRI results with R27. MRI results show early osteomyelitis in R27's right ankle . continue IV Vanco for 4 more weeks and restart Cipro 500mg twice daily for another 10 days .
3/31/22 NN: MD rounded . ordered CT Angiograms (type of diagnostic to check for blockage of arterial system) of both left lower extremity and right lower extremity .
5/4/22 NN: Wound Care
2nd digit 2.0cm x 1.2cm with intact eschar. Noted drainage between 2nd and 3rd digit. No open areas noted. Pink. Toes appear edematous.
Dorsum of foot 6.5cm x 11.6cm x <0.1cm. Tissue is very fragile and wound bed has a mixture of slough, granulation tissue, but a film of bioburden.
(It is important to note these are the first recorded wound measurements since 3/10/22.)
5/9/22 NN: R27's right lower leg bandage was soaked through .
5/18/22 Wound Care:
Dorsum of right foot medial aspect at boney prominence there is an area that measures 1.4cm x 1.9cm. This is intact with thin layer of healing tissue. This area remains very fragile.
Dorsum of right foot/large area 12cm x 4cm. This tissue is edematous with much Bioburden. The 2nd,3rd,4th digits are also involved. Heel inspected with no breakdown noted . placed pressure boot to foot .
(It is important to note these are the first recorded measurements since 5/4/22.)
5/19/22 NN: Wound culture obtained from dorsum of right foot as ordered.
5/21/22 NN: . wound culture came back Pseudomonas . start Cipro 750mg two times daily with no stop date at this time .
5/22/22 NN: R27 remains on Cipro 750 twice daily for a total of 7 days for right foot infection. Noted that her right foot is more swollen than previously seen. The area of slough that was near her inner ankle is healed but the area is now raised. Her great right toe is swollen. Slough bed present across foot base of toes .
5/25/22 NN: writer removed old dressing . old dressing saturated with serous drainage. Wound bed prior to cleansing was very moist drainage.
Dorsum wound is larger in size this week. 8.5cm x 17cm x undetermined. In the center of this wound there is a firm yellow slough area that measures 0.5cm x 0.5cm x 0.1cm, Wound bed is light yellow with peri-wound light pink. Will follow up with MD .
5/27/22 NN: dressing saturated .
5/28/22 NN: dressing saturated .
5/29/22 NN: Large amount of yellow fluid on old dressing . Right foot and lower leg are red . Has several areas on lower extremity that are weeping . was started again on doxycycline with no end date to help prevent infection.
5/30/22 NN: . remains on prophylaxis antibiotics . right foot dressing was soaked through kerlix dressing. Noted at base of toes slough bed . Discussed dressing has increased in weeping .needs to be changed 4 times during the day. Boot remains in place . She does not elevate her right leg.
5/31/22 NN: wounds measured .
Dorsum R foot medial aspect bony prominence 0.7 x 1 x 0.1
6/1/22 MD Progress Note: R27 presents for evaluation of chronic ulcerations of dorsum of the right foot . The nursing home is continuing to do wound care with cleansing of the wounds and applying Aquacel silver to the wounds . Removal of the Aquacel silver reveals erythema and slight maceration dorsally. She has severe contractures of the digits 2-5 and ulcerations are noted with drainage noted. Allergies: adhesive tape .
6/8/22 NN: Extensive drainage noted to old dressing.
Bony Prominence: 1cm x 1.5cm x <0.1cm. Center . has large patch of a thick dark yellow slough.
Right heel: Noted new deep tissue injury. This wound measures 2.5cm x 3.4cm x undetermined depth. Distal edge is open and draining clear drainage. The lower leg is taut with extensive drainage while doing dressing change. The skin is very fragile/friable with erosion appearance. Also found a white macerated band from the lateral aspect of the foot to the medial aspect. This appears to be from a foam dressing that had been placed the last dressing change. Applied Aquacel Ag to wounds and covered with ABDs and wrapped with Kerlix followed by a stockinette dressing to hold in place. We feel the new deep tissue injury may be due to using the EZ stand lift and the heel was not placed correctly to the floor of the lift which could attribute to this injury.
(It is important to note the new DTI to the heel and the possible cause recorded here with the EZ stand floor.)
6/8/22 MD Progress Note: reason for visit . follow up right foot open wound and deep tissue injury and osteomyelitis . is on oral doxycycline 100mg twice daily for right lateral malleolar osteomyelitis and is off IV Vancomycin. Has macerated right foot and open wound on heel from deep tissue injury . There has been leaking of the tissue fluid through the dressings at night and these have been reinforced and replaced. If appears to be worsening need to order further imaging, see if osteomyelitis is still an issue. Has no significant leg pain but has macerated right leg and open wounds to right leg. Please see RN wound nurse note of 6/8/22.
6/12/22 MD Progress Note: Problems: suspected deep tissue injury of unknown depth . Early osteomyelitis of the right ankle was given IV Vancomycin that seem to reduce the redness of the lateral malleolar area that seem to be the issue but whereas the right lateral malleolar area is healed she has a deep tissue injury ulcer on the right heel and burn scalding over some of right foot and plantar surface of right foot and pretibial area. (This can occur from infection.) Will need to restart vancomycin . CBC, CMP, ESR, CRP, Procalcitonin . Patient has significant neuropathy of right leg and does not feel pain unless significantly pressure is given to the wound . Suspected Deep Tissue Injury of unknown depth of heel: 3.2cm x 2.0cm right heel. Will see MD on 7/7/22 for recheck .Will be asking nursing to evaluate patient to see about large volume of weeping and redness of the wound if debridement is not going to be necessary for this right foot and leg .
6/14/22 NN: PICC (Peripherally Inserted Central Catheter) line intact and IV antibiotic started .
6/15/22 NN: Dressing to right lower extremity changed as ordered due to saturation from serous drainage .
6/15/22 Wound Assessment:
Dorsum R (right) foot medial aspect bony prominence 0.7 x 1.0 x 0.1
Heel 1.8x 3.5 x 0
6/22/22 Wound Assessment:
Dorsum R foot medial aspect bony prominence 0.5 x 1.0 x.0.0
Heel 2.5 x 3 x 0.3 - (worsening)
6/24/22 Wound Assessment:
Dorsum R foot medial aspect bony prominence 0.5 x 1.0 x.0.0
Heel: 2.5 x 3 x 0.3
(It is important to note these are the last measurements documented in R27's medical record.)
6/28/22 Wound Assessment:
Dorsum R foot medial aspect bony prominence 2.1 x 0.6 x 0.0
Heel: No measurements
(It is important to note these are the last documented measurements in R27's record the dorsum.)
7/3/22 MD Progress Note: . Right foot is totally and completely macerated significant weeping onto the 4x8s . is on IV antibiotics presently and does not seem to be improving . worsening . on oral Ciprofloxacin 500mg twice daily and clindamycin 300mg 3 times daily, will see MD 7/7/22 for evaluation of heel . for further treatment or surgery for .
7/7/22 MD Progress Note: R27 with daughter for evaluation of her right leg cellulitis and infection It has been a chronic condition with Pseudomonas infection and have been on antibiotic IV as well as by month. She has had a below the knee amputation to the left lower extremity secondary to the same type of condition that she has on the right. Exam: Ulceration is noted dorsally where she has severe contractures of the digits 2-5. She has a Charcot-[NAME] foot with neuropathy and has no sensation of pain or discomfort. There is erythema localized to the foot itself with new legion dorsally over the medial cuneiform region. She has necrotic type peeling skin stage 0-I ulcerations with no sinus tract or purulent drainage. There is quite a bit of drainage, but no purulent odor noted . At this time, I cleansed the wound with soapy water and debrided all of the necrotic skin dorsally. I applied Aquacel silver followed by Adaptic followed by sterile 4x4s and a kerlix dressing. An ace wrap was then applied to secure the dressing as well as control some of the edema .Possible consult to the UW infectious disease .
On 7/11/22 at 10:17 AM Surveyor, RN I (Registered Nurse) and RN J observed R27's wounds. During an interview R27 indicated she was a nurse for many years. R27 stated, My wounds started because I wore a shoe to match my prosthesis and it was too tight. RN I and RN J indicated that is how the wounds started. RN I indicated the heel wound started because R27's heel was not placed correctly on the EZ stand floor. R27 stated, That's right. RN I and R27 indicated R27 did not have boot on during that transfer and she should have to protect her fragile skin. RN I indicated R27 should have a boot on for all EZ stand transfers and while she is up, because R27 has such fragile skin on her leg and foot. R27 stated, I don't want to lose my right leg too. I am scared that might happen. RN I and RN J indicated R27's heel wound, t[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all residents receive treatment and care in accordance with pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents sampled for skin integrity (R27) out of a total sample of 14.
R27 was at risk for skin breakdown due to her diagnoses and health history patterns. R27 developed stasis ulcers and the facility failed to measure weekly per current standards of practice.
Evidenced by:
R27 was admitted to the facility on [DATE] with diagnoses, including CMT (Charcot-[NAME] Tooth disease), Neuropathy, and Amputation of left lower extremity below knee. CMT is a spectrum of nerve disorders that damage the nerves in the arms and legs.
R27's Medical Record contained the following:
2/8/22 NN (Nursing Notes):
Lateral aspect of right lower leg: 1.2cm x 0.7cm x undetermined. The wound bed has a thin translucent skin over wound. Wound bed shows ½ dry yellow slough and pinpoints of granulation.
The right lower leg is all over fragile .
2/13/22 NN: . right leg continues to have some redness, no increased warmth. R27 has no feeling in her right leg .no drainage noted .
2/15/22 MD Progress Note: R27 presents for re-evaluation of cellulitis in ulcerations on her right lower extremity.
2/17/22 MD Progress Note: . Reports new lesion . pretibial area redness and open sores to knee . Red swelling calf with [NAME] edematous tender calf area questionable heat to area but is swollen and red and tender . continue Cipro . [It is important to note the facility did not provide measurements related to the open sore on knee and has not recorded any measurements since 2/8/22.]
3/3/22 MD Progress Note: 1 right mid pretibial ulcer into dermis .
3/9/22 MD Progress Note: . looks a lot better with less erythema in her right lower extremity and no increased temperature. She still has some ulcerations in the midfoot area as well as on the anterior tibial region . I cleansed wounds with wound cleanser and applied Bactroban and sterile dressings .orders for nursing home . discussed antibiotic use with Pharmacist . continue Vanco IV as directed .
3/10/22 NN:
Lateral aspect of right lower leg 0.7cm x 0.2cm x 0.1cm. The wound bed has a thin translucent skin over wound. Wound bed shows yellow slough and is weeping.
Skin to right lower extremity is all over fragile and has potential for further skin breakdown. There are areas that are dry and crusty . Areas are cleaned with saline and Mupirocin was applied .
(It is important to note these are the first recorded measurements by MD or nursing staff since 2/8/22.)
5/4/22 NN: Wound Care
Right lower shin 1.2cm x 1.4cm x <0.1cm wound bed is 75% yellow slough and 25% beefy red. Peri-wound is pink and intact
(It is important to note these are the first recorded wound measurements since 3/10/22.)
5/18/22 Wound Care:
Right shin area measures 1cm x 2cm. This is dry intact eschar.
(It is important to note these are the first recorded measurements since 5/4/22.)
5/25/22 NN:
Shin open area: 0.9cm x 2cm x 0.1cm.
5/29/22 NN: Large amount of yellow fluid on old dressing . Right foot and lower leg are red . Has several areas on lower extremity that are weeping . was started again on doxycycline with no end date to help prevent infection.
5/31/22 NN: wounds measured .
Right lower leg shin 2.2 x 2.5 x 0.1 increased
6/8/22 NN: Extensive drainage noted to old dressing.
Shin: 2.5cm x 2.5cm with irregular margins .wound bed has 90%moist yellow slough and 10% islands of granulation. Surrounding tissue is crusty moist slough .
6/15/22 Wound Assessment:
Right lower leg shin Pressure Injury: 2.2 x 2.5 x 0.1
6/22/22 Wound Assessment:
Right lower leg shin: 1x2x0.1
6/24/22 Wound Assessment:
Right lower leg shin 2 x 2.5 x 0.1
6/28/22 Wound Assessment:
Right lower leg shin 2.2 x 2.0
(It is important to note these are the last documented measurements in R27's record for the shin.)
On 7/11/22 at 10:17 AM Surveyor, RN I and RN J indicated R27's wound on her shin is a stasis ulcer and they do not believe it is from pressure.
On 7/12/22 at 12:54 PM Surveyor and RN L observed R27's shin wound to not have any tendon or bone showing and was covered in slough. RN L indicated this wound is unstageable and not a stage 4 as NN suggested. RN L measured two shin wounds 5cm x 2.2 and 2cm x 3.2.
On 7/12/22 at 2:23 PM. MD O indicated R27 has stasis ulcer on shin/ankle, and he expects staff to do the same for those and measure on a weekly basis per current standards of practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2
R17 was admitted to the facility on [DATE]. R17 has diagnoses that include dementia with behavioral disturbance, chron...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2
R17 was admitted to the facility on [DATE]. R17 has diagnoses that include dementia with behavioral disturbance, chronic respiratory failure with hypoxia, malignant neoplasm of bilateral lungs, depression, anxiety disorder, and insomnia.
R17 was prescribed trazadone 100mg (miligrams) at bedtime PRN (as needed) for insomnia on 1//21/22. R17's care plan does not address insomnia, medications prescribed, side effects to monitor, or non-pharmacological interventions.
It is important to note that R17 also takes melatonin 6mg at bedtime for insomnia and lorazepam 0.5mg at bedtime for anxiety/ restlessness.
R17's MDS (Minimum Data Set) dated 4/28/22 Section D indicates that R17 has no trouble falling asleep, staying asleep, or sleeping too much.
Surveyor requested R17's sleep assessment from DON B (Director of Nursing), and was never provided the information.
On 7/12/22, at 10:10 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B for sleep monitoring logs and DON B indicated the facility does not have sleep monitoring logs.
Based on interview and record review, the facility did not ensure drug regimens are free from unnecessary psychotropic medications for 2 out of 5 residents (R21 and R17) reviewed for unnecessary medications out of a total sample of 14.
R21 receives Risperidone for dementia and Trazodone for insomnia. Risperidone is an antipsychotic medication that is used to treat psychotic conditions, such as schizophrenia and bipolar disorder. R21 was prescribed an antipsychotic medication without documentation of an appropriate diagnosis and targeted behaviors that are persistent and harmful to self and others. R21 was prescribed Trazodone for insomnia without prior sleep monitoring or non-pharmacological interventions attempted.
R17 receives Trazodone for insomnia. R17 was prescribed Trazodone for insomnia without prior sleep monitoring or non-pharmacological interventions attempted.
This is evidenced by:
The facility policy, entitled Administrative Policy- Long Term Care- Psychotropic Medication, undated, states, in part: POLICY: 1. Psychotropic medications are any drug used to treat or modify a psychiatric symptom or challenging behavior. 2. A written doctor's order will be obtained to include the Diagnosis or Target Behavior being treated. 5. Residents on psychotropic drugs will be assessed each shift for side effects and effectiveness of med.
Example1
R21 was admitted to the facility on [DATE] and has diagnoses that include Unspecified Dementia with Behavioral Disturbance, Delirium due to known physiological condition and insomnia.
R21's Quarterly MDS (Minimum Data Set) Assessment, dated 5/9/22, indicated that R21 has a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment.
R21's Care Plan, dated 1/26/22, with a target date of 8/18/22, states, in part: LTC (Long Term Care): Psychosocial Wellbeing Status: Inactive .
*LTC: ADL (Activities of Daily Living) .Related to: Unspecified dementia with behavioral disturbance, Delirium d/t known physiological condition, .insomnia .Needs: .For my insomnia I need psychotropic medications at this time, with monitoring by nursing .Intervention: .Assist me with my psychotropic medication for my sleep and monitor effectiveness .
Note: No behaviors or delirium with interventions regarding antipsychotic use. No indication of non-pharmacological interventions being used prior to medication.
R21's Physician Orders state, in part: .Risperidone 1mg [milligram] tablet po [by mouth] BID [two times a day] 84 [at 8 and 4] Scheduled Trazodone HCL [hydrochloride] 100mg tablet PO BEDTIME scheduled .
Note: No indications for use.
R21's Physician Progress Note, dated 6/17/22, states, in part: .Assessment and Plan (1) Dementia: Status: Chronic Assessment and Plan: He continues on risperidone. Qualifiers: Dementia behavioral disturbance: with behavioral disturbance Dementia type: unspecified type Qualified Code (s): F03.91- Unspecified dementia with behavioral disturbance .
R21's Informed Consent for Medication- Risperidone, dated 1/31/22, states, in part: .Reason for Use of Psychotropic Medication .Unspecified Dementia with Behavioral Disturbance .
R21's behaviors being monitored are striking out at staff and self-transferring. The month of May 2022 R21 had 7 behaviors documented of striking out at staff. The month of June 2022 R21 had no behaviors documented. From July 1, 2022, to July 11, 2022, R21 had no behaviors documented. This is not indicated as being a harmful and persistent behavior.
Note: No delirium being monitored.
On 7/11/22, at 1:54 PM, Surveyor interviewed CNA (Certified Nursing Assistant) D, who indicated R21 sometimes will hit towards staff but does not connect. Surveyor asked CNA D if R21 has behaviors that are persistent and harmful to self or other residents. CNA D indicated no.
On 7/11/22, at 1:58 PM, Surveyor interviewed CNA E and asked if R21 has harmful and persistent behaviors to self or other residents. CNA E indicated no, R21 mostly sleeps all the time.
On 7/12/22, at 10:10 AM, Surveyor interviewed DON B (Director of Nursing) and asked what diagnosis R21 has for the use of Risperidone. DON B indicated dementia. Surveyor asked DON B if dementia was an appropriate diagnosis for Risperidone and DON B stated, According to the doctor - yes. Surveyor asked DON B if R21 has behaviors and DON B indicated in the past R21 would strike out at staff and self-transfer. Surveyor asked DON B if R21 has behaviors that are harmful and persistent to self or others and DON B indicated no while looking at behavior monitoring. Surveyor asked DON B for sleep monitoring logs and DON B indicated the facility does not have sleep monitoring logs. Surveyor asked DON B if there were non-pharmacological interventions attempted prior Trazodone. DON B indicated they tried non-pharmacological interventions but there is no documentation to show it. Surveyor asked for a sleep assessment for R21 prior to Trazodone and no sleep assessment was provided to Surveyor.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not maintain an infection control program designed to prevent the dev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during care observations involving 1 Resident (R11) of 14 sampled residents.
Staff did not follow appropriate infection control practices when emptying R11's urinary draining bag (UDB).
The Facility is not reviewing their Infection Control Policies and Procedures annually.
This is evidenced by:
The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the CDC (Centers for Disease Control and Prevention) entitled, Guideline for Hand Hygiene in Health Care Settings, indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The above information can also be found at: https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on January 8, 2021.
The facility procedure Hand Hygiene (Washing or Decontaminating with Alcohol Products) undated, in part states .2A.1) Alcohol products may be used before and after having direct contact with patients .
07/11/22 09:07 AM Surveyor observed CNA H (Certified Nursing Assistant) empty R11's UDB into a clear plastic urinal. Surveyor followed CNA H entering room. CNA H donned gloves, placed down paper towel barrier, wiped spout with alcohol, drained urine, wiped with alcohol, and replaced UDB under bed. Urine measured and emptied, rinsed with water and placed on side of toilet, gloves removed, washed hands. Surveyor asked CNA H if she should wash per hands prior to procedure, CNA H replied yes and she should have washed her hands.
7/11/22 at 9:55AM Surveyor interviewed ICP C and updated on R11's observation with CNA H. ICP C replied that she was new and had been here a few months and should have washed her hands.
The following Infection Control Policies and Procedures are dated further back or not dated than annually for infection control:
COVID-19 Testing- no date for reviewed
Emergency Mandatory COVID-19 Vaccination Plan During the Pandemic, no date reviewed
Pandemic/Emergency Outbreak of Respiratory Illness, no date
Isolation of a Resident with a Communicable Disease, Review date 6/12
Epidemic/Infection Prevention, no review date
Infection Prevention Surveillance, no review date
Standard Precautions, no review date
Isolation, no date
New Employee Orientation, Infection Control, no date
Prevention and Control of MRSA and other Antibiotic Resistant Organisms in the facility, no dates
Hand Hygiene, no date
Protocol for Administering Pneumococcal Vaccine, approved [DATE], no review date
Infection Control Surveillance, no date
Optimize the use of antimicrobials for residents of LTC, no date
Influenza Immunization, no date
Coronavirus/COVID-19 Management Plan, reviewed 08/18/2020
7/13/22 at 4:45PM Surveyor reported polices are procedures are not updated annually. NHA A(Nursing Home Administrator) stated that policies are reviewed online and will provide an update.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and potential side effects of the influenza and pneumococcal immunization for 3 of 5 residents (R31, R8, and R28) reviewed for immunizations.
R31 refused the influenza and pneumococcal vaccine according to the facility vaccination list. There is no documentation R31 was offered education on the risks and potential side effects of the vaccine.
R8 refused the influenza vaccine according to the facility vaccination list. There is no documentation R8 was offered risks and potential side effects of the vaccine.
R28 refused the influenza and pneumococcal vaccine according to the facility vaccination list. There is no documentation R28 was offered risks and potential side effects of the vaccine.
This is evidenced by:
The facility's administrative policy Influenza Immunization undated, documents in part: A. Each resident or resident's legal representative will receive education regarding the benefits and potential side effects of the immunization .C. The resident or the resident's legal representative has the opportunity to refuse immunization. D. The resident's medical record will include documentation, including education that was provided regarding the benefits and potential side effects and if the resident either received the influenza immunization or did not receive due to medical contraindication or refusal .
The facility's departmental procedure Protocol for Administering Pneumococcal Vaccine, undated, documents in part: Purpose: To reduce morbidity and mortality from invasive pneumococcal disease by vaccinating all patients who meet criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. Pneumococcal vaccine will be offered year-round to MBMC (Mile Bluff Medical Center) patients who meet CDC (Centers of Disease Control) established immunization criteria .
Example 1
R31 was admitted to the facility on [DATE]. R31 did not have documentation in their medical record indicating the influenza and pneumococcal vaccination benefits and side effects were discussed. R31 had not received any doses of the influenza and pneumococcal vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and potential side effects of the influenza and pneumococcal vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 2/15/22 of vaccination refusal and education provided after the Surveyor inquired regarding vaccine education.
Example 2
R8 was admitted to the facility on [DATE]. R8 did not have documentation in their medical record indicating the influenza vaccination benefits and risks were discussed. R8 had not received any dose of the influenza vaccine, nor was there any documentation in her EHR indicating that the facility had provided education regarding the risks and potential side effects of the influenza vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 1/28/22 of vaccination refusal and education provided after the Surveyor inquired regarding vaccine education.
On 7/12/22 at 9:55AM, Surveyor interviewed R8 regarding vaccinations being offered, education provided and signing documentation of refusal. R8 replied there was not much talk of anything, I was asked if I had one, I said no, I was asked if I wanted one, I said no. R8 reports there was not a discussion of education and no handouts or teaching material was provided. R8 does not recall if forms what forms were signed.
Example 3
R28 was admitted to the facility on [DATE]. R28 did not have documentation in their medical record indicating influenza and pneumococcal vaccination benefits and risks were discussed. R28 had not received any doses of the influenza and pneumococcal vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and potential side effects of the influenza and pneumococcal vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/12/22 for the date of 5/17/22 of vaccination refusal and education provided after the Surveyor inquired regarding vaccine education.
On 7/11/22 at 10:11AM. Surveyor interviewed ICP C (Infection Control Preventionist) and asked where the immunizations are located in the EHR. ICP C reports of sometimes there is a message in the record, and later provided a sample of a message in the EHR and a sample of the education that is provided to residents. ICP C further reported due to the changing of staff she is unsure if they are in a binder or located someplace else. ICP C stated she is trying to pick up where staff have left off.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not develop a comprehensive person-centered care plan for 6 of 14 sampled ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not develop a comprehensive person-centered care plan for 6 of 14 sampled Residents (R11, R17, R24, R12, R21, R29) reviewed for person centered care plans.
R11 does not have a care plan for the use of an anticoagulant.
R17 does not have a care plan for the use of specific psychotropic medications.
R24 does not have a care plan for pain.
R21 does not have a care plan for specific psychotropic medications or the use of an anticoagulant.
R29 was prescribed an anticoagulant and her comprehensive care plan did not identify her risk with this medication and have interventions and goals in place regarding the use of anticoagulant medication.
R12 was prescribed an anticoagulant and her comprehensive care plan did not identify her risk with this medication and have interventions and goals in place regarding the use of anticoagulant medication
This is evidenced by:
The facility's policy titled, Multidisciplinary Plan of Care, no date, states in part: 1 The multidisciplinary plan of care includes the following: a. Identified resident needs. b. Identified goals which are realistic and described in terms that are measurable, related to a reasonable achievement of time, or maintenance of highest functional level. c. Approach to meeting identified goals .
On 7/12/22 at 10:10 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectation were for staff when developing a care plan, DON B stated that the care plan should be started on admission and adjust as needed. Surveyor asked DON B if she would expect that a resident who is receiving an anticoagulant, have a care plan for identifying that he/she is on an anticoagulant, DON B stated that she was unsure if anticoagulants are reflected on the care plan and is unsure if she would expect it to be there. Surveyor asked DON B if she would expect a resident who has pain to have a care plan for pain, DON B stated that if the resident has chronic pain, they should have a care plan for it, but if it's acute pain they do not create a care plan for it.
Example 1
R11 was admitted to the facility on [DATE]. R11 has diagnoses that include Type 2 Diabetes Mellitus, chronic pulmonary embolism, history of venous thrombosis and embolism, and a history of falling.
R11 is taking the anticoagulant, warfarin, daily.
R11's care plan does not address the use of an anti-coagulant or that staff should be monitoring for bruising or bleeding.
Example 2
R17 was admitted to the facility on [DATE]. R17 has diagnoses that include dementia with behavioral disturbance, chronic respiratory failure with hypoxia, malignant neoplasm of bilateral lungs, depression, anxiety disorder, and insomnia.
R17 was prescribed melatonin and trazadone for insomnia.
R17's care plan does not address insomnia, medications used for insomnia, side effects to monitor for, or non-pharmacological interventions that have been implemented.
Example 3
R24 was admitted to the facility on [DATE]. R24 has diagnoses that include acute and chronic respiratory failure with hypoxia, congestive heart failure, chronic kidney disease, cutaneous abscess to perineum, and pain.
R24 is prescribed acetaminophen 500 mg (milligrams) scheduled four times a day and PRN (as needed), hydrocodone/acetaminophen 5/325 mg scheduled four times per day, and morphine sulfate immediate release 15 mg every 4 hours as needed.
R24's care plan does not address her pain, pain medications, side effects to monitor for, or non-pharmacological interventions that have been implemented.
On 7/7/22 at 10:39 AM, Surveyor interviewed R24. Surveyor asked R24 how her pain was, R24 stated that it has been worse the last couple of days, but that she thinks that the facility was doing what they could. Surveyor asked if the facility has tried any non-pharmacological interventions such as a warm compress, ice, or repositioning, R24 stated that she was unsure.
Example 4
R21 was admitted to the facility on [DATE]. R21 has diagnoses that include Unspecified Dementia with Behavioral Disturbance and Chronic Atrial Fibrillation.
R21 is currently taking an anticoagulant, warfarin, daily.
R21's care plan does not reflect the use of an anticoagulant or how staff should monitor R21 for bruising or bleeding. R21 is currently taking Risperidone for unspecified dementia with behavioral disturbance.
R21's care plan does not reflect the use of Risperidone, behaviors or interventions put into place for use.
On 7/12/22 at 10:10 AM, Surveyor interviewed DON B and asked if R21's care plan should indicate antipsychotic use and interventions. DON B indicated possibly initially. DON B indicated interventions and antipsychotic use could be removed when behaviors no longer exists. Surveyor asked DON B if R21's care plan should indicate anticoagulant use and interventions. DON B indicated she does not know if she would expect interventions and anticoagulant use to be on the care plan. DON B indicated she would look into it.
Example 5:
R29 was admitted to the facility on [DATE] with diagnoses, including: chronic pulmonary embolism
R29 Physician Orders, for July 2022, include: Apixiban for chronic pulmonary embolism
R29's Comprehensive Care Plan, initiated 2/7/22, does not identify R29 to be on a high risk anticoagulant medication and does not contain interventions or goals related to the use of an anticoagulant.
Example 6:
R12 was admitted to the facility on [DATE] with diagnoses, including: Chronic pulmonary embolism and Chronic embolism and thrombosis of left popliteal vein.
R12's Physician Orders, for July 2022, include: Apixiban for Chronic pulmonary embolism.
R12's Comprehensive Care Plan, initiated 4/18/22, does not identify R12 to be on a high risk anticoagulant medication and does not contain interventions or goals related to the use of an anticoagulant.
On 7/11/22 at 3:20 PM DON B (Director of Nursing) indicated to Surveyor she was not sure if R29's and R12's Comprehensive Care Plan should include interventions and goals related to their use of an anticoagulants.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that a resident's medical record included documentation that i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that a resident's medical record included documentation that indicates the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and that the resident (or representative) either accepted, received, or declined the COVID-19 vaccine for 5 of 5 supplemental residents (R31, R8, R189, R28, R25) reviewed for COVID-19 vaccinations.
This is evidenced by:
The Centers for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) Memo (Ref: QSO-21-19-NH) released on May 11, 2021, addresses the Interim Final Rule related to COVID-19 Vaccine Immunization Requirements for Residents and Staff, which includes requirements for educating residents or resident representatives and staff regarding the benefits and potential side effects associated with the COVID-19 vaccine, and offering the vaccine. Additionally, the facility must maintain appropriate documentation to reflect that the facility provided the required COVID-19 vaccine education, and whether the resident or staff member received the vaccine.
According to the facility's vaccination tracking log, R31, R8, R189, R28, and R25 are unvaccinated for COVID-19.
Example 1
R31 was admitted to the facility on [DATE]. R31 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R31 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 2/15/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status.
Example 2
R8 was admitted to the facility on [DATE]. R8 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R8 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 1/28/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status.
On 7/12/22 at 9:55AM, Surveyor interviewed R8 of the COVID vaccinations being offered, education provided and signing documentation of refusal. R8 replied there was not much talk of anything, I was asked if I had one, I said no, I was asked if I wanted one, I said no. R8 reports there was not a discussion of education and no handouts or teaching material was provided. R8 does not recall if forms what forms were signed.
Example 3
R189 was admitted to the facility on [DATE]. R189 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R189 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/12/22 for the date of 6/10/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status.
Example 4
R28 was admitted to the facility on [DATE]. R28 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R28 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/12/22 for the date of 5/17/22 of vaccination refusal and education provided after the Surveyor inquired about it.
Example 5
R25 was admitted to the facility on [DATE]. R25 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R25 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 2/07/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status.
On 7/11/22 at 10:11AM. Surveyor interviewed ICP C (Infection Control Preventionist) and asked where the immunizations are located in the EHR. ICP C reports of sometimes there is a message in the record, and later provided a sample of a message in the EHR and a sample of the education that is provided to residents. ICP C further reported due to the changing of staff she is unsure if they are in a binder or located someplace else. ICP C stated she is trying to pick up where staff have left off.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has a potential to affect all 4...
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Based on observation, interview and record review the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has a potential to affect all 40 (R) residents who reside in the facility.
*Surveyor observed 45 individual nectar thickened lemon-flavored waters with expiration dates of 6/18/22.
*Surveyor observed the sugar and flour bins with no dates.
*Surveyor observed 4 individual containers of pureed peaches with use by date of 6/28/22.
*Surveyor observed a half of pan of blondie bars with use by date of 6/30/22.
*Surveyor observed a pan of coffee cake with use by date of 6/28/22.
*Surveyor observed 5 pints of whole milk with an expiration date of 6/29/22.
*Surveyor observed 1 pint of 1% milk with an expiration date of 6/29/22.
*Surveyor observed an opened 5-gallon pal of vanilla ice cream with no open date.
*Surveyor observed an orange twin popsicle opened with half the popsicle removed and no open date. Surveyor observed a cherry twin popsicle with half the popsicle removed taped shut with no open date.
This is evidenced by:
The facility policy, entitled Mile Bluff Medical Center-Food Storage and Dating, undated, states, in part: .PURPOSE: To ensure food items are stored and used properly according to national guidelines. PROCEDURE: 1. All food items that are taken out of original packaging must be dated with expiration date from original package .3. All food items in original packaging that are delivered to nourishment centers must contain an opened date and use by date .Staff that open items in the nourishment center must date items with opened date and use by date .
The facility policy, entitled Mile Bluff Medical Center- Storage of Food and Supplies, undated, states, in part: POLICY: .12. Food that has passed its expiration date will be discarded . 16. Open food packages/cans will be stored in airtight containers and dated with opened date .PURPOSE: To assure food and nonfood items are stored properly according to National guidelines .
On 7/6/22, at 10:17 AM, Surveyor conducted the initial walk through in the kitchen with DM (Dietary Manager) F finding the following:
Surveyor observed 45 individual containers of nectar thickened lemon-flavored water with an expiration date of 6/18/22 in the dry storage area. Surveyor asked DM F if the nectar thickened lemon-flavored waters were expired and DM F indicated yes. DM F removed all 45 containers of nectar thickened lemon-flavored waters from shelf and disposed of them.
Surveyor observed both the sugar and flour bins with no dates. Surveyor asked DM F what the process was for dating the flour and sugar. DM F indicated when the bins get empty the bins are then washed and new bags of flour and/or sugar are added to the bins. Then the date is put on the bins. DM F indicated there were no dates on the sugar or flour bins and should be.
Surveyor observed in the freezer 4 individual containers of pureed peaches with use by date of 6/28/22. DM F indicated the 4 individual containers of pureed peaches were expired and should not be in circulation.
Surveyor observed in the freezer a half pan of blondie bars with a use by date of 6/30/22 and a pan of coffee cake with a use by date of 6/28/22. Surveyor asked DM F if both pans are expired, and DM F indicated yes and disposed the pans.
On 7/6/22, at 10:53 AM, Surveyor observed in the refrigerator in the dining room, with 5 individual pints of whole milk and 1 pint of 1% milk with expiration dates of 6/29/22. Surveyor observed in the freezer an opened 5 gallon pal of vanilla ice cream with no open date. Surveyor observed an orange twin popsicle with 1 popsicle left in the package and no open date. Surveyor observed a cherry twin popsicle with 1 popsicle left in the package. The package was taped shut with no open date.
On 7/6/22, at 12:00 PM, Surveyor interviewed CNA (Certified Nursing Assistant) D and asked if the 5 pints of whole milk and 1 pint of 1% milk were expired. CNA D indicated yes and discarded the items. Surveyor asked CNA D if there was an open date on the 5-gallon pal of vanilla ice cream. CNA D indicated no. Surveyor asked CNA D if there was an open date on the orange and cherry twin popsicles. CNA D indicated no and disposed the items.
On 7/11/22, at 3:03 PM, Surveyor had kitchen exit with DD (Dietary Director) G and DM F and explained findings listed above.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Wisconsin facilities.
- • 38% turnover. Below Wisconsin's 48% average. Good staff retention means consistent care.
Concerns
- • 15 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Fair View's CMS Rating?
CMS assigns FAIR VIEW NURSING AND REHABILITATION CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Wisconsin, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Fair View Staffed?
CMS rates FAIR VIEW NURSING AND REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 38%, compared to the Wisconsin average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Fair View?
State health inspectors documented 15 deficiencies at FAIR VIEW NURSING AND REHABILITATION CENTER during 2022 to 2025. These included: 1 that caused actual resident harm and 14 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Fair View?
FAIR VIEW NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 50 certified beds and approximately 36 residents (about 72% occupancy), it is a smaller facility located in MAUSTON, Wisconsin.
How Does Fair View Compare to Other Wisconsin Nursing Homes?
Compared to the 100 nursing homes in Wisconsin, FAIR VIEW NURSING AND REHABILITATION CENTER's overall rating (4 stars) is above the state average of 3.0, staff turnover (38%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Fair View?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Fair View Safe?
Based on CMS inspection data, FAIR VIEW NURSING AND REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Wisconsin. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Fair View Stick Around?
FAIR VIEW NURSING AND REHABILITATION CENTER has a staff turnover rate of 38%, which is about average for Wisconsin nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Fair View Ever Fined?
FAIR VIEW NURSING AND REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Fair View on Any Federal Watch List?
FAIR VIEW NURSING AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.