Milwaukee Catholic Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R4) of 6 sampled residents reviewed for transfers.*R4 was assessed and care planned to transfer with a sit to stand mechanical lift (EZ stand) and assist of 2 staff. Surveyor observed Certified Nursing Assistant (CNA)-C transfer R4 with the sit to stand mechanical lift without the assistance of another staff member.Findings include:The facility policy titled, Transfer of a resident with the Sit to Stand dated 10/2025 documents: Policy: The safe transfer of a resident who is able to bear weight can be done with the Sit to Stand and the assist of one or two staff per plan of care (POC). Procedure: .4. Place sling under the arms of the resident with the padding next to resident. Be sure sling fits snugly. Adjust accordingly. R4 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis- Lumbar region, Type 2 Diabetes Mellitus…

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, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R4) of 1 sampled residents observed for incontinence cares. *Staff was observed not wearing appropriate personal protective equipment (PPE) while providing personal to R4. R4 was on Enhanced Barrier Precautions (EBP).Findings include:The facility policy titled Enhanced Barrier Precautions dated 4/2025 documents: Policy: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents and increased cost for the health care system. This policy will target gown and glove use during high contact resident care activities and is designated to reduce transmission of MDRO's. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDRO's that employs targeted gown and glove use during…

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, interview and record review, the facility did not ensure food was stored in a safe manner. This practice has the potential to affect all 22 residents located on the 2nd floor rehab unit. *The resident food refrigerators located in the medication (med) rooms have a desired temperature documented on the temperature log of 36 to 45 degrees Fahrenheit (F). The facility food storage policy documents that food refrigerators should be between 35 and 41 degrees. Surveyor observed the food refrigerator located in the 2nd floor Rehabilitation (Rehab) unit med room multiple times during survey. Surveyor observed the food refrigerator temp to be between 44 and 46 degrees on observations. The facility did not always document a temperature on the temperature log located in the 2nd floor Rehab med room. Findings include: The facility policy dated 7/24 titled, Storage of Medications documents, in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Medications requiring refrigeration or…

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 Observation and interview, the facility did not ensure the tube feeding pole for 1 (R39) of 1 Residents reviewed for cleanliness of tube feeding equipment, had equipment that was clean and operating in a sanitary manner. Multiple observations were made of R39's tube feeding pole having dried tube feeding splatter and adhered debris to the screen, base of pole and cord. Findings include: On 05/29/2025, at 08:30 AM, R39 asked for the tube feeding to be disconnected. Surveyor observed Licensed Practical Nurse (LPN)-G disconnect R39's tubing, removed the tubing from under R39's bottom while on the commode and then hang the tubing on R39's tube feeding pole. Surveyor noted that R39's tube feeding pole was also covered in crust and unknown matter at the base of the pole and the black power cord had debris built up on it. On 06/02/2025, at 08:41 AM, Surveyor noted that R39's tube feeding pole was still filthy with crusty unknown matter consistent with tube feeding, on the screen, black power cord, and base of pole. On 06/02/2025, at 08:41 AM, Surveyor noted R39's tube feeding pole…

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 and interview the facility did not maintain infection prevention and control designed to reduce the transmission of disease and infection for 1 (R39) of 1 resident reviewed for bowel and bladder cares. *On 05/29/2025, Surveyor observed R39 with R39's tubing for their feeding tube under R39 while having a bowel movement, while on R39's bedside commode. Surveyor observed Licensed Practical Nurse (LPN)-G disconnect R39's tubing from R39's feeding tube port, remove the tubing from under R39, hang the tubing back on R39's tube feeding pole, then reconnect R39's tubing to R39's feeding tube port once R39 had returned to R39's chair. On 05/29/2025, Surveyor observed CNA-F clean R39 after a bowel movement, then handed R39 a washcloth with unchanged, dirty gloves, to clean R39's peri area. On 06/03/2025, Surveyor observed CNA-I bring a clear garbage bag of washcloths from the bathroom into R39's room. CNA-I pulled a washcloth from the garbage bag and began wiping R39's buttocks. CNA-I then dropped…

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, record review and interview, the facility did not ensure food was stored and prepared safely, in 1 (kitchen on 2nd floor) of 2 kitchens. This deficient practice has the potential to affect residents residing on 2 East who receive their meals from the second-floor kitchenette. *Cook-C used gloved hand to touch ready to eat food after touching multiple surfaces. Findings: The facility policy, entitled Food Safety Requirements - Use, Storage, Procurement, dated 1/2018, states: It is the policy of this Milwaukee Catholic Home to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. Factors implicated in foodborne illnesses: Poor personal hygiene - personal health and hygiene are significant factors in preventing foodborne illness .Proper hand washing techniques and exclusion of infectious workers from handling food are critical for prevention of foodborne illness. On 02/08/24 at 07:49 AM, Surveyor along with Director of Dining Services-E observed Cook-C in the second-floor…

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 interview and record review the Facility did not notify a Resident's representative and attending physician when there was a change of condition involving 1 (R25) of 20 residents reviewed for notification of a representative. * R25 developed a stage 2 pressure injury to the left heel. There was no documentation R25's representative or attending physician were updated when the change of condition occurred. Findings include: Facility policy entitled, Pressure Injury Protocol, last revised 2/2023 states: Stage 2 Pressure Injury . L. Keep physician and resident's representative advised of current treatment plan. Surveyor noted according to the State Operations Manual, §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- . (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in…

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, interview and record review the facility did not revise resident care plans for 2 (R84 and R25) of 20 resident care plans reviewed. *R84 developed a facility acquired stage 3 pressure injury to the right buttock. R84's care plan was not revised to include interventions for the stage 3 pressure injury. *R25 developed a facility acquired stage 2 pressure injury to the left heel. R25's care plan was not revised to include interventions for the stage 2 pressure injury. Findings include: The facility's policy entitled, Comprehensive Care Plan, revised date 9/2023, states: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. #6. The resident's care plan will be reviewed after each assessment, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. #7.…

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, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 of 9 (R25) residents reviewed for pressure injuries. * R25 did not have a comprehensive assessment with measurements or treatment put in place when a new stage two pressure ulcer of left heel was discovered on 1/29/2024 and was missing weekly assessments and measurements for 10 days until 2/8/2024. R25 was observed to not have heels supported off the bed or heel boots on during this time. Finding include: The facility policy titled Pressure Injury Documentation Sheets with a revision date of 11/2022 documents in part: Policy: It is the policy of facility to have documentation for all pressure related injuries. These sheets will enable staff to evaluate progress on a weekly/PRN basis. Procedure: 1.Wound measurements will be done…

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, interview, and record review, the facility did not ensure that 2 (R14 and R46) of 3 residents reviewed received dialysis services consistent with professional standards of practice. * R14 was admitted to the facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. There was no communication between the facility and the dialysis facility with each visit. * R46 did not have a physician's order documenting the frequency of dialysis treatments or the location of the dialysis center in the community. There was no communication between the facility and the dialysis center with each visit. Findings include: The facility policy entitled Dialysis Services revised on 1/2024 states: [Facility name] will work collaboratively with the resident's dialysis center to ensure a unified coordination of services. Procedure: . 4. Facility will send a consult sheet along with resident to appointments for communication purposes. 5. Facility will collaborate with…

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 record review and interview, the Facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action taken to address the identified concerns. This was observed with 1(R14) of 5 residents reviewed for medication regimen review. * R14 did not have monthly Pharmacy Medical Record Reviews completed and recommendations reviewed by the attending physician or Medical Director. Findings include: The Facility policy titled Medication Regimen Review (MRR) last approved 8/17/2023 documents (in part): Procedure 1. The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record . 7. The pharmacist will address copies of residents' MRRs to the Director of Nursing and the attending physician and to the Medical Director. Facility staff should ensure that 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 interview and record review the facility did not ensure 2 (R82 and R14) of 3 resident were free from PRN (as needed) psychotropic medications. * On 12/28/23 R82 was prescribed Lorazepam (anti-anxiety medication) 1 mg every two hours PRN without a stop date. * On 10/17/23 R14 was prescribed Lorazepam 0.5 mg twice daily PRN without a stop date. Findings include: Surveyor reviewed the facility's Policy and Procedure, Psychotropic Medications dated 11/2022, noting the following as applicable: PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN anti-psychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. The goal is to monitor the resident's outcome, quality of life and functional capacity, while using psychotropic medications only when needed to treat a specific condition that is diagnosed and documented. In…

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, interview, and record review the facility did not ensure a resident received routine dental services for 1 (R1) of 1 resident reviewed for dental services. The facility did not arrange routine dental services for R1. Findings include: The facility policy entitled Dental Services revised on 1/2024 states: The facility will assist residents in obtaining routine and 24-hour emergency dental care. PROCEDURE: 1.The facility- a.Will provide or obtain from an outside resource, the following dental services to meet the needs of each resident: i. routine dental services (to extent covered under the State plan) . b.Will, if necessary or if requested, assist the resident- i. In making appointments; and ii. By arranging for transportation to and from the dental services locations. R1 was admitted to the facility on [DATE] and has diagnoses that include dysphagia- oropharyngeal phase (difficulty swallowing), dementia, anxiety disorder, altered mental status, anorexia (lack or loss of appetite for food),…

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.