Juliette Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a resident representative provided informed consent and was aware of the risks and benefits of prescribed psychotropic medication and monitored prescription medication for 1 resident (R) (R5) of 5 sampled residents.R5 had orders for Buspar (an antianxiety medication), gabapentin (an anticonvulsant medication/monitored prescription medication), venlafaxine (an antidepressant medication), and Rexulti (an atypical antipsychotic medication). The facility did not obtain written consent from R5's legal representative to administer the medications. Findings include:Wisconsin Statute 50.08(3)(fm)2 Informed consent for psychotropic medications indicates: Unless consent is withdrawn sooner, the informed consent is valid for the period specified on the informed consent form or for 15 months from the date on which the resident, or the person acting on behalf of the resident, signs the form, whichever is shorter.Between 4/6/26 and 4/8/26, Surveyor…

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 Based on staff interview and record review, the facility did not ensure the Office of the State Long Term Care Ombudsman was notified of hospital transfers for 1 resident (R) (R5) of 3 sampled residents.R5 was transferred to the hospital on [DATE] and [DATE]. Long Term Care Ombudsman (LTCO)-D was not notified of the hospital transfers. Findings include:The facility's Long Term Care (LTC) Discharge and Transfer Policy, revised [DATE], indicates: .7. The facility will forward a copy of all discharge/transfer notices to the Office of the State LTC Ombudsman.The facility provided Surveyor with the following forms:~ Department of Health Services (DHS) 132.53 Transfers & Discharges (no date indicated): This section shall apply to all resident transfers and discharges .(2) Conditions: (a) Prohibition & Exceptions: No resident may be discharged or transferred from a facility except .9. If the short-term care period for which the resident was admitted has expired. ~ Wisconsin DHS Division of Quality Assurance (DQA)…

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 Based on staff interview and record review, staff did not report an allegation of abuse in a timely manner for 1 resident (R) (R1) of 4 sampled residents.On 8/27/25, Certified Nursing Assistant (CNA)-C witnessed CNA-D yell and swear at R1. R1 reported that CNA-D told R1 to urinate in R1's brief. The allegation of abuse was not reported timely to Nursing Home Administrator (NHA)-A.Findings includeThe facility's Long Term Care (LTC) Resident Abuse Prevention and Reporting Policy, revised 4/11/25, indicates: .G. Reporting: 1. Anyone who witnesses an act that may potentially meet the definition of abuse or any other defined misconduct, or to whom someone has reported abuse or any other defined misconduct, will immediately ensure resident safety and then report the allegation to the Administrator. 2. The proper method of reporting is in-person or phone call to assure prompt notification is made .5. For alleged violations of abuse, or if there is serious bodily injury, the facility must report the allegation to 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 Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated and corrective actions were taken to prevent further abuse for 1 resident (R) (R1) of 4 sampled residents. On 8/27/25, Certified Nursing Assistant (CNA)-C witnessed CNA-D enter R1's room, yell and swear at R1, and tell R1 to urinate in R1's brief. The facility's investigation did not include thorough staff education on abuse prevention and reporting or ensure education retention. In addition, staff did not immediately intervene and remove CNA-D from resident care per the facility's policy.Findings include:The facility's Long Term Care (LTC) Resident Abuse Prevention and Reporting Policy, revised 4/11/25, states the purpose of the policy is to outline standards and processes to ensure: (1) Residents live in a safe environment where they are free from abuse and neglect and are treated with respect and dignity, and, (2) to be in compliance with state and federal laws and regulations.E.…

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 Based on staff interview and record review, the facility did not ensure therapeutic diets were followed for 5 residents (R235, R23, R184, R186, and R10) of 36 sampled residents. R235, R23 and R184 had orders for cardiac diets. R235, R23, and R184 did not receive their ordered diets for lunch on 2/4/25. R186 had an order for a renal diet. R186 did not receive R186's ordered diet for lunch on 2/4/25. R10 had an order for a cardiac/diabetic/renal diet. R10 did not receive R10's ordered diet for lunch on 2/4/25. Findings include: The facility's extended menu (that contains what residents on therapeutic diets should receive) for the 2/4/25 lunch meal indicated the following: ~General diet: Breaded chicken, mashed potatoes with gravy, carrots, a raspberry pocket, and milk ~Cardiac diet: Plain chicken breast, baked potato, fruit, and milk ~Renal diet: Grilled chicken breast, large garden salad, and fruit Between 2/4/25 and 2/5/25, Surveyor reviewed residents' medical records and diet orders and made the following…

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 Based on staff and resident interview and record review, the facility did not report an allegation of abuse to Nursing Home Administrator (NHA)-A or the State Agency (SA) in a timely manner for 1 resident (R) (R2) of 16 sampled residents. R2 reported to staff that Certified Nursing Assistant (CNA)-F was rough with cares and yelled at R2. The allegation of abuse was not reported timely to NHA-A or the SA. Findings include: The facility's Long Term Care (LTC) Resident Abuse Prevention and Reporting Policy, revised 9/12/24, indicates: .G. Reporting: 1. Anyone who witnesses an act that may potentially meet the definition of abuse or any other defined misconduct, or to whom someone has reported abuse or any other defined misconduct, will immediately ensure resident safety and then report the allegations to the Administrator. 2. The proper method of reporting is in-person or phone call to assure prompt notification is made .6. For alleged violations of abuse, or if there is serious bodily injury, the facility must…

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 Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R2) of 16 sampled residents. R2 reported that Certified Nursing Assistant (CNA)-F was rough with cares and yelled at R2. R2 informed staff that R2 did not want CNA-F to care for R2. CNA-F attempted to go back into R2's room to obtain R2's vital signs but R2 yelled at CNA-F to get out. CNA-F was not removed from or supervised during resident care until 1/22/25. Findings include: The facility's Long Term Care (LTC) Resident Abuse Prevention and Reporting Policy, revised 9/12/24, indicates: .E. Protection: 1. Immediately upon receiving a report of alleged abuse or any other defined misconduct, the facility will take all necessary steps to protect residents from additional harm. The facility will coordinate delivery of appropriate medical and/or psychological care and attention. 2. Safety, security, and support of the residents will be provided. The facility will…

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 Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R2) of 1 resident observed during wound care. Registered Nurse (RN)-C did not complete hand hygiene during wound vac dressing changes for R2. Findings include The facility's Long Term Care (LTC) Infection Prevention and Control Policy, dated 12/23/24, indicates: .2. Hand Decontamination: a. Team members will use an alcohol-based hand rub: .iii. Before and after resident contact; iv. After contact with a resident's surroundings or equipment; v. Prior to performing any aseptic procedures .vii. Prior to contact with a resident's invasive medical device . From 2/3/25 to 2/5/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had diagnoses including encounter for surgical after care following surgery on the circulatory system, hypertensive heart and chronic…

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 Based on observation, staff interview, and record review, the facility did not ensure appropriate supervision was implemented to ensure the safety of 3 residents (R) (R5, R6, and R7) of 8 sampled residents. On 3/1/24, R1 made a lewd comment to R5. The facility did not complete a thorough investigation. On 6/19/24, R1 asked R6 to expose R6's self while R1 watched from outside the window. The facility did not revise R1's care plan to provide sufficient supervision. On 8/9/24, R1 entered R7's room while R7 was sleeping. The facility did not complete a thorough investigation or revise R1's care plan to provide sufficient supervision. Findings include: The facility's LTC (Long Term Care) Resident Abuse Prevention & Reporting Policy, with a review date of 9/12/24, indicates: The purpose of this policy is .to ensure: (1) Residents live in a safe environment where they are free from abuse and neglect and are treated with respect and dignity .C. Prevention: .5. The population of LTC facilities present the following…

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.