Complete Care at Manitowoc LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure daily weights were consistently completed or a physician was notified of a significant weight gain for 1 resident (R) (R67) of 6 sampled residents.R67 had a diagnosis of congestive heart failure (CHF). R67 had an order for daily weights and to notify the physician of a weight gain of 3 pounds (lbs) or more in one day. R67 had a significant weight gain of 7.4 lbs (5.96%) from 9/19/25 to 9/20/25. Staff did not consistently complete daily weights or notify the physician of R67's weight gain.Findings include:The facility's Weight Monitoring policy, revised 5/28/25, indicates: Based on the resident's comprehensive assessment, the facility will ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .6. Weight analysis: 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 observation, staff interview, and record review, the facility did not provide services to prevent complications of enteral feeding for 1 resident (R) (R42) of 1 sampled resident with a feeding tube.R42 received medication, nutritional supplements, and hydration via gastrostomy (G)-tube. During an observation of medication administration, Licensed Practical Nurse (LPN)-D did not flush R42's G-tube with 10 cubic centimeters (ccs) of water between medications as ordered.Findings include:The facility's Medication Administration via Enteral Tube policy, dated 2025, indicates: It is the policy of this facility to ensure the safe and effective administration of medication via enteral feeding tube by using best practice guidelines .Each medication will be administered separately .Flush enteral feeding tube with at least 15 milliliters (ml) of water prior to administering medication unless otherwise ordered by the provider .Administer using a clean syringe .Flush tube again with at least 15 ml of water unless…

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 a medical record contained complete and accurate information for 1 resident (R) (R5) of 10 sampled residents.On 6/28/25, Registered Nurse (RN)-C assessed R5 for stroke symptoms after receiving a concern from R5's friend. RN-C did not document the neurological assessment in R5's medical record after it was completed.Findings include:The facility's Documentation in the Medical Record policy, revised 10/2024, indicates: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress .Licensed staff and Interdisciplinary Team members shall document all assessments, observations, and services provided in the resident's medical record .Documentation shall be completed at the time of service.On 7/7/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including stroke,…

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 provide appropriate care and services to prevent urinary tract infections (UTIs) for 2 residents (R) (R13 and R14) of 10 sampled residents. On 11/26/24, R13 and R14's catheter drainage bags were observed on the floor. Findings include: The facility's Catheter Care Policy, dated 6/2024, indicates: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use .(The policy does not address positioning/placement of tubing or drainage bags.) The facility's Urinary Catheter Relias training indicates: .Urinary catheters often lead to infections and complications .as many as 50-70% of urinary catheter-related infections can be prevented. You are in a position to prevent infections and complications caused by…

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.

Based on observation, staff interview, and record review, the facility did not follow a prescribed individualized diet to ensure nutritional needs were met for 1 resident (R) (R11) of 8 sampled residents. During the 11/26/24 lunch meal, staff did not follow R11's consistent carbohydrate (CCHO) diet order. Findings include: The facility's Menu Parameters Standardized Diets policy, revised 3/24/20, indicates: Menus must meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences .The intent of this regulation is to assure that the meals served meet the nutritional needs of the resident in accordance with the recommended daily allowances (RDAs) of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences. This regulation also assures that there is a prepared menu by which nutritionally adequate meals have been planned for the resident and followed. During the lunch meal on 11/26/24, Surveyor noted R11 received a…

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.

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) (R8) of 14 residents observed during the provision of care. In addition, dietary staff touched items in the kitchen without completing hand hygiene. R8 was on enhanced barrier precautions (EBP) which required staff to wear personal protective equipment (PPE) during high-contact care. On 11/26/24, staff transferred R8 without wearing PPE. On 11/26/24, Dietary Aide (DA)-L lifted a garbage can lid with gloved hands. DA-L then wrapped food and touched items in the kitchen without completing hand hygiene. Findings include: The facility's Enhanced Barrier Precautions Policy and Procedure, revised 6/26/24, indicates: The implementation of EBP will reduce transmission of resistant organisms by employing targeted gown and glove use during high-contact resident care activities .Nursing home residents with wounds and indwelling medical devices are especially at risk of…

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.

Based on observation and staff interview, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 60 of 105 residents residing in the facility. On 7/23/24 and 7/24/24, beverages were not iced during meal service. The temperature of the milk at the end of meal service on 7/23/24 was 59 degrees Fahrenheit (F). Resident food was not heated in a microwave according to regulations or the facility's policy. Findings include: On 7/22/24 at 8:32 AM, Surveyor began an initial kitchen tour with Assistant Dietary Manager (ADM)-F who stated the facility follows the Wisconsin Food Code. Beverage Temperatures: The Wisconsin State Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding: (A) .Time/Temperature Control for Safety Food shall be maintained: (2) At 41 degrees F or less. The facility's Record of Food Temperatures policy, dated January 2024, indicates: .4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees F. On 7/23/24 at 11:22 AM, 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 observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent a pressure injury from developing and/or promote healing for 1 resident (R) (R161) of 5 sampled residents. R161 had a history of a stage 2 pressure injury on the sacral/coccyx area. R161's skin integrity care plan contained an intervention for a pressure reducing cushion while up in chair. During an observation on 7/24/24, R161 did not have a cushion in R161's recliner. Findings include: The facility's Pressure Injury Risk Assessment Policy, dated 6/23, indicates: It is our policy to perform a pressure injury risk assessment as part of our systemic approach to pressure injury prevention. A risk assessment does not always identify who will develop a pressure injury, but will determine which residents are more likely to develop a pressure injury .3. Each item on the standardized risk assessment will be considered, individually, to ensure risk factors are addressed appropriately,…

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 it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 25 opportunities which resulted in an 8% medication error rate that affected 1 resident (R) (R18) of 12 residents observed during medication pass. On 7/22/24, R18 was administered an incorrect dose of two eye drops. Findings include: The facility's Medication Administration policy, with a revision date of June 2024, indicates: .10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation. Compare medication source with Medication Administration Record (MAR) to verify resident name, medication name, form, dose, route, and time . On 7/22/24, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] with diagnoses including unspecified macular degeneration 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 Based on staff and provider interview, and record review, the facility did not promptly notify the provider and/or Power of Attorney for Healthcare (POAHC) of a change in condition for 2 Residents (R) (R1 and R5) of 2 residents. R1's provider was not notified timely of an increase in R1's sexual behaviors and a sexual encounter between R1 and R5. R5's POAHC and provider were not notified timely of a sexual encounter between R5 and R1. Findings include: The facility's Notification of Changes policy, dated 6/2023, indicates: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. 1. On 9/14/23 and 9/18/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including dementia. R1's most recent Minimum Data Set (MDS) assessment, dated 7/23/23, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1…

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 failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act for 2 Residents (R) (R1 and R5) of 5 residents reviewed. R1 and R5 had activated [NAME] of Attorney for Healthcare (POAHC) due to impaired cognition. On 9/5/23, staff observed R1 touching R5's genitals in R5's room behind a closed door. The allegation of sexual abuse was not reported to the SA or law enforcement. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 9/2023, indicates: The facility will designate an Abuse Prevention Coordinator who is responsible for reporting allegations of suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with State law, and reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies (e.g., law enforcement…

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 resident and staff interview, and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 2 Residents (R) (R1 and R5) of 5 residents reviewed. The facility did not complete a thorough investigation regarding an allegation of sexual abuse after R1 and R5 were observed in a sexual encounter behind a closed door in R5's room. Findings include: The facility's Abuse, Neglect and Exploitation policy, revised 9/19/23, indicates: V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all…

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 medical record contained accurate and complete documentation for 2 Residents (R) (R1 and R5) of 5 sampled residents. The medical records for R1 and R5 did not contain complete and accurate documentation related to sexual interactions between R1 and R5. Findings include: The facility's Documentation in Medical Record policy, dated 6/2023, indicates: Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state laws and facility policy. On 9/14/23 and 9/18/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including dementia. R1's most recent Minimum Data Set (MDS) assessment, dated 7/23/23, contained a Brief Interview for Mental Status (BIMS) score of 3 out of 15 which indicated R1 was severely cognitively impaired. R1 required staff assistance with activities of daily living…

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.