St Marys Home for the Aged

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure reconciliation of discharge medications for 1 resident (R) (R51) of 2 sampled residents. R51 was private pay status and discharged to an Assisted Living (AL) facility on 8/25/25. Medications were not sent with R51 at the time of discharge. The pharmacy was not able to fill all of R51's medications because some were filled by the nursing facility less than 30 days prior. The facility delivered some medications to R51's AL facility on 8/26/25 but did not have a record of which medications were delivered. R51 missed three doses of a Parkinson's medication.Findings include:The facility's Discharge Planning policy, revised 3/31/17, indicates: .5. Implement Discharge Plan: .f. Communicate discharge plan to appropriate members of the care team.From 12/1/25 to 12/3/25, Surveyor reviewed R51's medical record. R51 was admitted to the facility on [DATE] following a hospital stay from 7/20/25 to 8/5/25 due to respiratory failure secondary to pericardial…

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 representative interview and record review, the facility did not ensure a new diagnosis of schizophrenia met clinical criteria for 1 resident (R) (R1) of 1 sampled resident.R1 was admitted to the facility on [DATE]. On 6/6/25, R1 received a new diagnosis of schizophrenia. The facility did not have evidence that R1's diagnosis met the diagnostic criteria in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Findings includeAccording to The American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (a resource used by mental health professionals to diagnose mental disorders), to meet the criteria for a diagnosis of schizophrenia, the patient must have experienced two (or more) of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated). At least one of these must be delusions, hallucinations, or disorganized speech: delusions;…

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 representative interview and record review, the facility did not provide restorative therapy to increase and/or prevent decrease in range of motion (ROM) or activities of daily living (ADLs) for 1 resident (R) (R51) of 1 sampled resident.Power of Attorney for Healthcare (POAHC)-K received notice on 8/19/25 that R51's Medicare benefits were ending. Therapy was not provided while POAHC-K pursued an appeal.Findings include:The Notice of Medicare Non-Coverage (NOMNC) form indicates: .You have the right to appeal this decision to end Medicare coverage for your services. This means you'll get an independent medical review right away. Your services will continue during the appeal. From 12/1/25 to 12/3/25, Surveyor reviewed R51's medical record. R51 was admitted to the facility on [DATE] following a hospital stay from 7/20/25 to 8/5/25 where R51 had respiratory failure thought to be secondary to pericardial effusion and possible pneumonia. R51 was intubated and received a pacemaker during 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 ensure the resident environment remained as free of accident hazards as possible for 2 residents (R) (R23 and R12) of 3 sampled residents.R23 had a history of falls. R23's care plan contained an intervention for a call light within reach with prompt response to requests. During multiple observations, R23 did not have a call light within reach.R12 had a history of falls. R12's care plan contained an intervention to have a walker in front of R12 when in bed and in R12's recliner. During multiple observations, R12 did not have a walker in front of R12 when in bed or the recliner.Findings include: The facility's Fall Prevention Program policy, revised 1/8/19, indicates: .1. Ensure the environment is free from accident hazards over which we have control and that we provide supervision and assistive devices to each resident to prevent avoidable accidents in accordance with state and federal regulations. 1. On 12/1/25, Surveyor reviewed…

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 and resident interview, and record review, the facility did not provide necessary respiratory care and services for 2 residents (R) (R1 and R5) of 2 sampled residents.R1 had diagnoses of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD). R1 had an order for a bilevel positive airway pressure (BiPAP) machine with oxygen provided by a concentrator and connected to the machine via tubing. Staff did not clean R1's BiPAP machine per manufacturer's instructions. In addition, two open one-gallon jugs of distilled water for use with R1's BiPAP machine were expired. R5 had a diagnosis of OSA and an order for a continuous positive airway pressure (CPAP) machine. Staff did not clean R5's CPAP machine per manufacturer's instructions.Findings include:The facility's Using a CPAP machine policy, dated [DATE], indicates: CPAP is used to treat patients with obstructive sleep apnea or to help decrease a patient's work of breathing while increasing oxygen saturation in 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 maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R42, R11, and R1) of 16 sampled residents. R42 was on droplet precautions. Staff provided care for R42 without wearing personal protective equipment (PPE).R11 was on contact precautions. Staff provided care for R11 without wearing PPE. R1 had a diagnosis of pneumonia. R1 was not listed on the facility's infection control resident line list for surveillance. Findings include:The facility's Infection Prevention and Control Program policy, revised 1/1/25, indicates: .4. The Infection Prevention Committee (ICP) will make recommendations about how to best maintain a safe, sanitary, and comfortable environment for residents and staff and how to prevent the development and transmission of disease and infection .11. All residents on transmission precautions (contact, droplet,…

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 Significant Change in Status (SCIS) Minimum Data Set (MDS) assessment was completed timely for 1 resident (R) (R1) of 3 sampled residents. R1 met the criteria for a Significant Change in Status MDS assessment on 3/15/25. A SCIS assessment was not completed. Findings include: The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) manual 3.0 states a Significant Change in Status MDS must be completed when the Interdisciplinary Team determines a resident meets the significant change guidelines for either a major decline or a major improvement. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review…

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 vaccinations were reviewed, offered, or administered for 1 Resident (R) (R13) of 5 sampled residents. The facility did not offer R13 the PCV20® vaccine. Findings include: Abbreviations (www.cdc.gov): PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13®) PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvance®) PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar 20®) PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax23®) The most recent Centers for Disease Control and Prevention (CDC) recommendations for pneumococcal vaccinations indicate: For adults 65 years or older who have only received PPSV23, the CDC recommends: Give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For those who have received PCV13 and 1…

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 ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 30 residents residing in the facility. Cold food items were served outside the temperature safe zone and dessert was not covered appropriately during meal service. Hand hygiene was not completed appropriately during lunch service on 6/20/22. Findings include: On 6/21/23 at 1:20 PM, Certified Dietary Manager (CDM)-E stated the facility follows the Wisconsin Food Code. 1. Cold Temperature Foods/Uncovered Items The Wisconsin Food Code at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding states: .Time/Temperature control for safety food shall be maintained: .(2) At 5 degrees Celsius (41 degrees Fahrenheit) or less. The Wisconsin Food Code also states at 3-307.11 Miscellaneous Sources of Contamination: Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 and 3-306. The facility's Food Temperature Verification…

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 comprehensive care plans were developed for 3 Residents (R) (R6, R12, and R22) of 13 sampled residents. The facility did not develop a hospice care plans for R6 and R12 when R6 and R12 started hospice services. The facility did not develop a care plan which included the intervention of a splint to R22's left arm. Findings include: 1. R6 was admitted to the facility on [DATE] and had diagnoses that included encounter for palliative care, Alzheimer's disease with late onset, adult failure to thrive, and vascular dementia. Between 6/20/23 and 6/22/23, Surveyor reviewed R6's medical record and noted R6 started hospice services on 2/27/23. R6's medical record did not contain a plan of care for hospice services. On 6/22/23 at 9:38 AM, Nurse Manager (NM)-C confirmed R6 did not have a care plan related to hospice services and stated one was just added. Surveyor again reviewed R6's medical record and noted a hospice care plan was added on 6/22/23. 2.…

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 the accurate administration of medication for 1 Resident (R) (R4) of 13 sampled residents. R4 did not receive scheduled pain medication timely when the facility ran out of the medication and did not have a current prescription. Findings include: R4 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, presence of cardiac pacemaker, generalized anxiety disorder, radiculopathy lumbar region (inflammation of a nerve root in the lower back which causes symptoms of pain or irritation in the back and down the legs .commonly referred to as sciatica). R4's most recent Minimum Data Set (MDS), dated [DATE], contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R4 was not cognitively impaired. R4 had a care plan related to pain. On [DATE] at 9:55 AM, Surveyor interviewed R4 who stated R4 did not get R4's scheduled hydrocodone (a narcotic medication used to treat moderate…

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 staff interview and record review, the facility did not ensure monitoring of a high-risk medication for 1 Resident (R) (R15) of 5 residents reviewed. R15's medical record did not contain monitoring for the side effects of Lasix (a diuretic medication). Findings include: According to the Davis's Drug Guide for Nurses 18th edition copyright 2023 adverse reactions/side effects of diuretic medication include thirst, dry mouth, lethargy, weakness, hypotension, and oliguria (abnormally small amouts of urine) .Monitor daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes .Monitor blood pressure and pulse before and during administration. On 6/22/23, Surveyor reviewed R15's medical record and noted R15 had a physician's order for Lasix 20 mg (milligrams) (a loop diuretic (water pill) that prevents the body from absorbing too much salt) daily for a diagnosis of congenital heart failure. Surveyor noted R15's medical record did not include monitoring for side effects or adverse reactions to Lasix. On 6/22/23 at 9:16 AM,…

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.