Rock County Hospital Long Term Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l) Based on observations, record review, and interview; the facility failed to identify causal factors for the development and/or revision of fall prevention interventions and to implement fall interventions for 4 (Residents 1, 2, 3, and 4) of 4 sampled residents. The facility census was 20. Findings are: A. Review of the Fall Prevention and Treatment Long Term Care policy dated 6/25revealed the purpose of the policy was to prevent any unintended falls. Each resident was assessed for fall risk and was to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident was to be screened at admission, quarterly and with any significant change of status. The following procedure was identified:-upon admission, the nurse will complete the Morse Fall assessment along with the nurse assessment to determine the resident's level of fall risk. -the nurse would indicate on the resident's care plan what the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review and interview; the facility failed to handle food in a manner that prevented potential food borne illness. This had the potential to affect all facility residents. The census was 18. Findings are: Review of the facility policy Proper use of Gloves with a revision date of 7/2013 revealed the purpose was to prevent disease and food borne illness. This included the following procedures: -Washing hands before gloving and when changing to a new pair of gloves. -Putting on new gloves before handling ready-to-eat foods such as sandwiches, and when handling fresh produce.-Prolonged use of a single pair of gloves could result in excess perspiration, which could be ideal for bacterial growth.-Disposable gloves were for one-time use.During observation of food service occurring from the portable steam table in the dining room on 9/9/25 from 11:55 AM through 12:15 PM the following was observed. -Dietary Aid B washed hands, put on gloves, took a food order from a resident while touching the back of the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09A Based on record review and interview; the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed related to a mental health diagnosis for Resident 3. The sample size was 1 and the facility census was 18. Findings are:Review of the facility policy Pre-admission Screening and Resident Review and admission dated 10/2024 revealed the following:-the review process was designed to identify individuals with Serious Mental Illness (SMI), Intellectual or Developmental Disabilities (IDD), or both, and to ensure they received the necessary specialized services and appropriate placement in accordance with federal and state guidelines,-the facility established a standard process that facilitated comprehensive screening, assessment, and decision-making to determine the eligibility and appropriate level of care for individuals seeking admission to a nursing home,-the discharging hospital or nursing home conducted an initial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review; the facility failed to ensure Resident 3 received trauma informed care related to a diagnosis of Post Traumatic Stress Disorder (PTSD) and to identify triggers and implement approaches to mitigate potential triggers. The sample size was 1 and the facility census was 18. Findings are:Review of the facility policy Trauma Informed Care dated 4/2025 revealed the following:-it was the policy of the facility to ensure residents who were trauma survivors received culturally competent, trauma informed care in accordance with professional standards of practice,-trauma was defined as an event or series of events or set of circumstances experienced by an individual as physically or emotionally harmful or life-threatening, that had lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being,-trauma informed care was defined as organizational structure and treatment framework that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to implement infection control practices to prevent the potential spread of Covid-19 infection related to testing a symptomatic resident (Resident 4) for COVID-19. The sample size was 2 and the census was 18. Findings are: A. Review of the facility Infectious Patient, Communicable Disease, Pandemic Plan with a revised date of 1/2025 revealed the purpose of the policy was to include plans and actions to respond to the threat of Covid-19 and to prevent transmission. Staff and residents were to be tested for Covid-19 if onset of symptoms develop. B. Review of Resident 4's Nursing Progress Notes revealed the following:-5/21/25 at 7:52 PM the resident had a runny nose and a cough at times. There was no evidence the resident was tested for COVID-19. -5/22/25 at 4:57 AM the resident reported feels like crud with a temperature of 99.1 degrees Fahrenheit. -5/22/25 at 7:04 PM the Director of Nursing (DON) was called, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I)(i)(3)(4) Based on record review and interview; the facility failed to put interventions in place and/or revise interventions to prevent ongoing falls for Residents 8 and 24. The sample size was 4 and the facility census was 25. Findings are: A. Review of the facility policy Fall Prevention and Treatment last approved 1/2024 revealed the following: -upon admission a fall assessment would be completed to determine the resident's level of fall risk, -the nurse would indicate in the resident's care plan what the fall risk was then implement interventions in accordance with the fall risk level, -if the resident was at a high risk for falls, they would be placed on the facilities fall prevention program and additional interventions would be provided as directed by the resident assessment, and -when a resident experienced a fall the facility would assess the resident, notify the physician, family, and Director of Nursing (DON), review the resident's care plan and update…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview; the facility Pharmacist failed to identify medication irregularities related to a diagnosis for an antipsychotic medication for Resident 15, failed to ensure Resident 22's antibiotic medication had a clinical rationale to support ongoing daily use, failed to ensure a gradual dose reduction was attempted or there was a clinical rationale for continued use of Resident 11's antidepressant medication, and failed to ensure Resident's 8, 24, and 25's as needed antipsychotic medication orders did not exceed 14 days without a providers reassessment of the resident's conditions. The sample size was 7 and the facility census was 27. Findings are: A. Review of the facility policy Use of Psychotropic Drugs with a review date of 8/2023 revealed the following: -Resident were not given psychotropic (mind altering substance that changes brain function and can alter perception) drugs unless the medication was necessary to treat a specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 12-006.09(H) Based on record review and interview; the facility failed to ensure antibiotic medication orders for Resident 22 had the required duration of use or a documented rationale for continued daily use in accordance with facility policies and clinical standards. The sample size was 7 and the facility census was 27. Findings are: Review of the facility policy Antibiotic Stewardship-LTC with a revision date of 11/2018 revealed the following: -The facility followed an antibiotic stewardship policy -The purpose of the program was to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. -The facility tracked antibiotic use daily. -The facility communicated with physician with the use of a quarterly report card. Review of the facility policy Antibiotic Stewardship with a revision date of 3/2024 revealed the following: -The facility had a coordinated program that promoted the appropriate use of antimicrobial agents, improved outcomes, minimized adverse effects, reduced antimicrobial resistance, and decreased the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review; the facility failed to have a diagnosis for the use of an antipsychotic (medication typically used to manage psychotic disorders) medication for Resident 15, failed to attempt a gradual dose reduction or have a documented contraindication for reducing an antidepressant (medication typically used to treat depression) medication for Resident 11, and failed to ensure PRN (as needed) antipsychotic medications orders were limited to 14 days for Residents 8, 24, and 25. The sample size was 7 and the facility census was 27. A. Review of the facility policy Use of Psychotropic Drugs with a review date of 8/2023 revealed the following: -Residents were not given psychotropic (mind altering substance that changes brain function and can alter perception) drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to submit a completed investigation report to the State Agency for a fall for Resident 8. The sample size was 3 and the facility census was 25. Findings are: Review of the facility policy Abuse Neglect and Exploitation last approved 9/23 revealed the following: -when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurred, an investigation would immediately be warranted, -when abuse, neglect, or exploitation was suspected the nurse would respond to the resident needs and protect them from further incidents; notify the Director of Nursing (DON) and the Administrator; initiate an investigation immediately; notify the physician, the resident's representative and contact the State Agency to report the alleged abuse, -in response to alleged allegations the facility must ensure all alleged violations were reported immediately to the Abuse and Neglect Hotline no later than 2 hours after the allegation was made or no later than 24 hours if the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review and interview; the facility failed to review and revise Resident 10's Care Plan addressing pressure ulcer risk prior to the resident developing a pressure injury/s (injury to skin and or underlying tissue caused by prolonged pressure to skin). The sample size was 18 and the facility census was 27. Findings are: Review of the facility policy Pressure Injury Prevention and Management with a review date of 7/2023 revealed the following: -The facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure ulcers. -A Pressure Ulcer/Injury referred to localized damage to skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. -Avoidable meant the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define, and implement interventions that were consistent with the resident's needs,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

F. Observation on 8/19/24 at 9:10 AM RN-E obtained Resident 20's medications from the medication cart. RN-E placed the oral medications into a medication cup and obtained a topical medication in a tube and went to the resident room. RN-E donned a gown, gloves, and mask and entered the resident room. Resident 20 was still in bed and RN-E placed the medication cup and the topical medication on the resident's bedside table without a barrier. RN-E administered the resident's oral medications and gave the resident a sip of water. The resident started to spit out the medications and RN-E caught the medications in RN-E's gloved hand. RN-E removed their gloves and discarded, then put on a new pair without performing hand hygiene. RN-E obtained the topical medication from the resident's bedside table and applied the medication. RN-E placed the medication tube back onto the resident's bedside table and removed their gloves and did not perform hand hygiene. RN-E picked up the medication and removed their gown before exiting the resident room. RN-E went back to the medication cart and placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.