Oconto Health and Rehab Center

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 reported to the State Agency (SA) for 1 resident (R) (R1) of 19 sampled residents. R1 indicated Certified Nursing Assistant (CNA)-E was abusive to R1. R1 reported the incident to staff. The allegation of abuse was not reported to the SA. Findings include: The facility's Abuse, Neglect, and Exploitation policy, dated 12/2/24, indicates: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .the facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services, and to all other required agencies within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . From 3/11/25 to 3/12/25, Surveyor reviewed R1's medical…

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, facility did not thoroughly investigate an allegation of abuse for 1 resident (R) (R1) of 19 sampled residents. R1 and R1's Power of Attorney for Healthcare ((POAHC)-J) reported an allegation of physical abuse to staff that involved Certified Nursing Assistant (CNA)-E. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse, Neglect and Exploitation policy, dated 12/2/24, indicates: 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; .3 Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on…

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 showers, feeding assistance, and activities of daily living (ADLs) were performed by a qualified person for 2 residents (R) (R15 and R19) of 19 sampled residents. This practice had the potential to affect more than 4 of the 41 residents residing in the facility. The facility did not ensure Hospitality Aide (HA)-D performed responsibilities that were within HA-D's scope of practice when HA-D assisted with showering, feeding, and transferring R15 and R19. Findings include: On 3/11/25 at 6:26 PM, Surveyor interviewed R15 who indicated HA-D completed cares, showers, and transfers for R15 and assisted with washing and getting R15 dressed. (R15 wished to remain anonymous. R15's most recent Minimum Data Set (MDS) assessment indicated R15 was not cognitively impaired.) On 3/12/25, Surveyor reviewed the job description and responsibilities for Hospitality Aides provided by Nursing Home Administrator (NHA)-A. Surveyor reviewed a Hospitality Aide document, signed by HA-D on 1/29/25, that indicated: To provide support 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.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R10) of 1 resident observed during the provision of cares. R10 had an indwelling catheter and was on enhanced barrier precautions (EBP). On 3/11/25, Certified Nursing Assistant (CNA)-E and CNA-F did not wear gowns while completing personal hygiene and catheter care for R10. In addition, Registered Nurse (RN)-G did not wear a gown or complete hand hygiene between glove changes during wound care for R10. Finding include: The facility's Enhanced Barrier Precautions policy, dated 2/5/25, indicates: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident cares .initiation of EBP: .i. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters .) .Implementation of EBP: a. Make…

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 physician and Guardian were notified of medication refusals for 1 resident (R) (R3) of 11 sampled residents. R3 refused multiple medications in January and February of 2025. The facility did not notify R3's physician or Guardian. Findings include: The facility's Medication Administration policy, dated 1/2024, indicates: .2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .If two consecutive doses of a vital medication are withheld or refused, the physician is notified. On 2/12/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, hypertension, obsessive compulsive disorder (OCD), depression, disruptive mood dysregulation disorder, personality disorder, and dysphagia (difficulty swallowing). R3's Minimum Data Set (MDS) assessment, dated 12/16/24, had a Brief Interview…

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 representative interview, and record review, the facility did not provide treatment and services to prevent weight loss and hydration for 2 residents (R) (R3 and R1) of 11 sampled residents. R3 had an order for a mechanical soft diet with ground meat. On 12/20/24, a swallow study and speech therapy evaluation was requested for a possible diet upgrade. On 12/30/24, Speech Therapy (ST) upgraded R3's diet, however, R3's diet order was not changed. As of 2/12/25, the swallow study was not completed. In addition, R3's meal intakes were not consistently documented. R1 was at risk for dehydration. Staff did not consistently document or monitor R1's fluid intake to determine if hydration interventions were effective. Findings include: The facility's Nutritional Management policy, dated 4/9/24, indicates: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall…

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 pharmaceutical services to meet the needs of 2 residents (R) (R5 and R6) of 4 sampled residents. R5 did not receive calcium 200 milligrams (mg) as ordered during the AM medication pass on 2/12/25. In addition, staff did not update R5's physician regarding the missed medication. R6 did not receive Seroquel XR 50 mg as ordered during the AM medication pass on 2/12/25. Findings include: The facility's Medication Administration Policy, revised 11/12/24, indicates: .10. Ensure that the six rights of medication administration are followed .b. Right drug .11. Review Medication Administration Record (MAR) to identify medication to be administered .22. If medication is unable to be administered due to the unavailability of the medication, notify the pharmacy to obtain alternative medication options, to include contingency availability, and consult with the physician . 1. On 2/12/25, Surveyor reviewed R5's medical record. R5 was…

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 allow 1 resident (R) (R2) of 3 sampled residents to set up a petty cash fund or Resident Fund Management Service (RFMS) account. R2's Corporate Guardian (CG)-H asked the facility to set up a resident account for R2. CG-H was told an account could not be set up and the facility could not cash checks for R2 unless CG-H provided direct deposit account information. Findings include: The facility's Resident Personal Funds policy, revised 7/4/24, indicates: .2) If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. Deposit of Funds: .3) Residents whose care is funded by Medicaid; the facility will deposit the residents' personal funds in excess of $50 in an interest-bearing account separate from any of the facility'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 Based on observation, staff interview, and record review, the facility did not ensure services were provided to prevent further decrease in range of motion for 1 resident (R) (R1) of 8 sampled residents. R1's plan of care did not contain interventions to address R1's contracted left hand. Findings include: On 11/22/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, amputation of right hand, and hemiplegia (paralysis/immobility of one side of the body) following cerebral infarction (also known as stroke) affecting the left side. R1's Minimum Data Set (MDS) assessment, dated 10/26/24, indicated R1 was rarely/never understood. R1's medical record indicated R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. On 11/22/24 at 9:11 AM, Surveyor observed R1 in bed. Surveyor noted R1 had a below-the-elbow amputation of the right arm and R1's left hand/fingers were contracted and contained 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not consistently monitor nutrition/hydration intake for 1 resident (R) (R1) of 3 sampled residents. R1 had orders for one-on-one feeding assistance and meal and fluid intake to be documented each meal. Staff did not consistently document those items. In addition, R1's care plan was not updated with an intervention for staff to offer and provide R1 water every hour. Findings include: On 11/22/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus, amputation of right hand, and hemiplegia (paralysis/immobility of one side of the body) following cerebral infarction (also known as stroke) affecting the left side. R1's Minimum Data Set (MDS) assessment, dated 10/26/24, indicated R1 was rarely/never understood. R1's medical record indicated R1 had a Power of Attorney for Healthcare (POAHC) who was responsible for R1's healthcare decisions. R1's medical record indicated…

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 provide appropriate medically-related social services for 1 resident (R) (R1) of 3 sampled residents. R1's hospital discharge summary indicated R1 had a history of a suicide attempt, was followed by a psychiatrist in the community, and had psychotropic medication discontinued while in the hospital prior to admission to the facility. The facility did not follow-up and assist R1 with the continuance of psychiatric services or attempt to expedite the guardianship process (example: request for emergency protective placement) in a timely manner when R1 left the facility multiple times and demonstrated unsafe behavior. Findings include: The facility's Elopements and Wandering Residents policy, with a revision date of 9/16/23, indicates: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan 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 staff interview and record review, the facility did not ensure their abuse policy was implemented for 2 of 8 employees reviewed for background checks. The facility did not complete an out-of-state background check for Director of Nursing (DON)-B. The facility did not have a completed Background Information Disclosure (BID) form for Laundry Aide (LA)-C. Findings include: The facility's Abuse, Neglect, and Exploitation policy, with an implementation date of 9/18/23, indicates: Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential new employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants .3. The facility will maintain documentation of proof that the screening occurred. On 8/20/24, Surveyor reviewed DON-B's background check information. DON-B was hired on 2/28/20. DON-B's four year BID form was completed on 1/5/24. DON-B checked Yes to question 4 which…

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 maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 2 (Human Resources (HR)-G and Certified Nursing Assistant (CNA)-F) of 3 staff reviewed for infection surveillance and 4 residents (R) (R13, R32, R23, and R189) of 14 sampled residents. This practice had the potential to affect all 35 residents residing in the facility. The facility did not complete details of a staff illness line list used for infection surveillance for HR-G and CNA-F. During an observation on 7/2/24, CNA-I did not perform appropriate hand hygiene during the provision of care for R13. During an observation on 7/2/24, R32's room contained used personal protective equipment (PPE). In addition, medical supplies were stored in R32's room. During an observation on 7/2/24, Licensed Practical Nurse (LPN)-J did not sanitize a blood pressure…

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 ensure a self-administration of medication assessment was accurately completed for 1 resident (R) (R11) of 4 sampled residents. On 7/2/24, Surveyor observed medication at R11's bedside. A self-administration of medication assessment and physician's order did not accurately reflect the medications R11 was allowed to self-administer. In addition, R11's plan of care did not indicate how R11 would store and secure the medications kept in R11's room. Findings include: The facility's Resident Self-Administration of Medication policy, with copyright date of 2024, indicates: .14. The care plan must reflect resident self-administration and storage arrangements for such medications. On 7/2/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and hypertension. R11's Minimum Data Set (MDS) assessment, dated 6/26/24, had a Brief Interview for Mental Status…

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 Pre-admission Screen and Resident Review (PASRR) requirements were met for 1 resident (R) (R7) of 14 sampled residents. R7's PASRR Level I Screen was completed inaccurately, therefore, a PASRR Level II Screen was not completed. Findings include: The Department of Health Services (DHS) document titled Preadmission Screen and Resident Review (PASRR) Level I Screen (F-22191), with a revision date of 7/2017, indicates: Nursing facilities must not admit any new resident who is suspected of having a serious mental illness or a developmental disability unless the State mental health authority/State developmental disability authority or designee has evaluated the person and determined if the person needs nursing facility placement and if the person needs specialized services .If a Level II Screen is required, the information on the (Level I) form is matched with information from the person's Level II Screen to ensure the facility, the department'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 Based on observation, staff and resident interview, and record review, the facility did not ensure comprehensive resident-centered care plans were implemented for 2 residents (R) (R7 and R15) of 14 sampled residents. On 7/2/24, Surveyor observed a bed rail on R7's bed. R7's care plan did not indicate the need for a bed rail. R15 had a history of being sexually assaulted. R15's care plan did not contain information related to R15's request for no caregivers of the opposite gender. Findings include: The facility's Proper Use of Bed Rails policy, with a copyright date 2023, indicates: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails .16. Responsibilities of ongoing monitoring and supervision are specified as follows: a. Direct care staff will be responsible for care and treatment in accordance with the plan of care. On 7/1/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease 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.

Based on observation, staff and resident interview, and record review, the facility did not ensure nail care was provided for 1 resident (R) (R21) of 14 sampled residents who required assistance with activities of daily living (ADL). Staff did not provide toenail clipping and cleaning for R21. Findings include: The facility's undated Nail Care Policy indicates: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .2. Identify conditions that increase risk for foot or nail problems, such as diabetes .4. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift or shower day). Nail care will be provided between scheduled occasions as the need arises .Principles of nail care: a. Nails should be kept smooth to avoid skin injury. On 7/2/24, Surveyor reviewed R21's medical record. R21 had diagnoses including fractured left pubis, emphysema, and asthma. R21's Minimum Data Set (MDS) assessment, dated 5/15/24, had a Brief Interview for Mental…

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 ensure medical records contained accurate and complete documentation for 2 residents (R) (R7 and R10) of 14 sampled residents. On 7/2/24, Surveyor observed a bed rail on R7's bed. R7's care plan did not indicate the need for a bed rail and R7's medical record did not contain documentation of assessments staff indicated were completed. R10's cane was taken away by staff. R10's medical record did not contain documentation of a discussion with R10 regarding the removal and under what conditions R10 could have the cane returned. Findings include: 1. On 7/1/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and fibromyalgia. R7's Minimum Data Set (MDS) assessment, dated 4/6/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R7 had moderate cognitive impairment. The MDS assessment did not indicate R7 used bed…

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 staff and resident interview, the facility did not ensure 3 residents (R) (R1, R7, and R8) of 9 sampled residents had call lights within reach. R1, R7, and R8 were observed in their rooms without a call light within reach or a means to notify staff if assistance was needed. Findings include: On 6/3/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction with left sided paralysis, below elbow amputation of right arm, and anxiety disorder. R1's Minimum Data Set (MDS) assessment, dated 5/12/24, stated R1's Brief Interview for Mental Status (BIMS) score was 12 out of 15 which indicated R1 had minimal cognitive impairment. R1's medical record indicated R1's Power of Attorney for Healthcare (POAHC) was responsible for R1's healthcare decisions. R1's care plan included the intervention Place call light within reach with no specific instruction regarding what type of call light or placement was needed to accommodate R1'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 Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 1 resident (R) (R1) of 9 sampled residents. In addition, the facility did not provide pharmaceutical services to ensure the safe handling of drugs and biologicals for 1 (R9) of 11 residents observed during medication administration. R1 did not receive multiple doses of hydrocortisone (a steroid medication) as ordered by R1's physician. During medication pass on [DATE], Surveyor noted slot 2 of R9's second card of buspirone (used to treat anxiety) contained a half pill that was taped in the slot. In addition, Surveyor observed Registered Nurse (RN)-C destroy a half tablet of buspirone by discarding it in the garbage. Findings include: The facility's undated Medication Administration policy indicates: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional…

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 thoroughly document, investigate, or resolve grievances for 2 residents (R) (R5 and R6) of 6 residents. R5 reported Certified Nursing Assistant (CNA)-C did not change R5's clothing from the day prior. The facility did not document, investigate, or thoroughly resolve the grievance. R6 reported that R6 was wet and CNA-C ignored R6. The facility did not document, investigate, or thoroughly resolve the grievance. Findings include: The facility's Resident and Family Grievances policy, dated 9/7/23, indicates: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination or reprisal .Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of the complaint/grievance .10. B. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist…

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 pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 3 Residents (R) (R1, R2, and R4) of 3 residents reviewed for medication administration. R1 received scheduled medications outside of the facility's acceptable time frame on 9/23/23, 9/27/23, 10/2/23, 10/7/23, and 10/10/23. In addition, R1's Lidocaine Patch was not applied on 10/11/23. R2's 12:00 PM medication was administered at 1:08 PM on 10/11/23. R4's 12:00 PM medication was administered at 1:10 PM on 10/11/2. Findings include: The facility's undated Timely Administration of Medication policy indicated: To ensure timely ordering and administration of medication .compare the medications available to the MAR (Medication Administration Record) for each resident .time to be administered. The facility's Medication Administration policy, with a copyright date of 2023, indicated:…

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 sanitary manner. This practice had the potential to affect 35 of 36 residents residing in the facility (One resident received nutrition exclusively via tube feeding.) Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Kitchen ceiling vents in the food preparation area contained visible dust. Cook (CK)-E did not wear a hairnet when CK-E entered the kitchen and began food preparation. The ice machine in the kitchen was not clean and contained a dusty filter. Findings include: Dietary Manager (DM)-D stated the facility followed the FDA (Food and Drug Administration) Food Code. 1. Sanitizing Solution Testing Quaternary test strips used by the facility contained a package insert that indicated the solution should be between 65 and 75 degrees Fahrenheit (F) at the time of testing. During an initial tour of the kitchen on 6/5/23 at 7:45 AM, DM-D stated staff used sanitizer buckets to clean kitchen prep and surface areas. DM-D also stated…

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 and resident interview, and record review, the facility did not provide a safe, clean, comfortable, and home-like environment for 10 Residents (R) (R37, R30, R33, R21, R2, R8, R29, R24, R27, and R25) of 18 sampled residents. During an observation in the main dining, Surveyor observed dead bugs in the ceiling lights, spiderwebs in the windowsills, stained and warped ceiling tiles and noted the condition of the walls needed repair. R33 stated the condition of the dining room prevented R33 from eating in the dining room for meals. During observations and resident interviews, Surveyor noted R37, R30, R33, R21, R2, R8, R29, R24, R27, and R25's rooms contained holes in the floor, cracked floor tiles, floors that were uneven and soft and/or stained ceiling tiles. R30, R21, and R25 stated the condition of their floors created difficulties with walking and room comfort. R25 and R33 stated the warped, brown and yellow stained ceiling tiles were not home-like. Findings include: 1. During an interview with R37 on 6/5/23 at 9:00 AM, Surveyor noted R37's floor was…

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 staff and resident interview, the facility did not ensure privacy during pericare for 2 Residents (R11 and R24) of 16 residents reviewed. During an observation of pericare for R24, Surveyor observed a nurse open the door and enter the room on two occasions. On both occasions, the privacy curtain was open and R24 was exposed. While staff assisted R11 with bed pan use, Surveyor entered the room and noted the privacy curtain was open. Findings include: 1. R24 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction and dysphagia. R24 resided in double room with another resident. R24 had a care plan that indicated: (R24) presents with an alteration in ability to communicate related to impaired speech, impaired cognition. (R24) has problems with reception, transmission of information. (R24) can become frustrated when unable to convey (R24's) message. (R24) has a communication board/computer. On 6/6/23 at 11:19 AM, Surveyor observed Registered Nurse (RN)-M enter…

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 ensure the appropriate care and services were provided to increase and/or prevent further decrease in range of motion for 1 Resident (R) (R27) of 16 residents reviewed. R27 had a leg brace to prevent contractures. The brace was not consistently offered or applied per R27's plan of care. Findings include: R27 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident (stroke). R27's Minimum Data Set (MDS) assessment, dated 5/5/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out 15 which indicated R27 did not have cognitive impairment. The MDS indicated R27 had impairment on one side for upper and lower extremity range of motion. On 6/6/23, Surveyor reviewed R27's medical record which contained a care plan that indicated R27 had limited physical mobility related to contractures. The care plan contained the following approach: Apply brace to left leg Q (every) AM 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.

Based on staff interview and record review, the facility did not ensure a Nursing Assistant (NA) completed a competency evaluation for 1 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA-H was employed by the facility as a CNA, but did not complete the Nurse Aide competency exam. Findings include: CNA-H was hired by the facility on 3/20/23 as a CNA. On 6/5/23, Surveyor requested background check and CNA registry information for CNA-H. On 6/6/23, Surveyor reviewed background check and Nurse Aide registry information for CNA-H. Surveyor reviewed a copy of CNA-H's Certificate of Successful Completion of Nurse Aide Program from (a local technical college), dated 10/11/22, but noted no Wisconsin Nurses Aide Registry information for CNA-H. Surveyor requested Wisconsin Nurses Aide Registry information for CNA-H from Nursing Home Administrator (NHA)-A. On 6/6/23 at 3:59 PM, Surveyor interviewed NHA-A who stated NHA-A was unaware that CNA-H was not on the Nurse Aide Registry until Surveyor asked for CNA-H's Nurses Aide Registry information. NHA-A stated CNA-H worked in the facility as 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not administer medications timely for 3 Residents (R) (R16, R15, and R11) of 16 residents. R16, R15 and R11 did not receive their AM medications within the facility's AM medication pass time frame on 6/3/23. Findings include: The facility's Medication Administration policy, copyright 2023, contained the following information: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this State, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. R16 was admitted to the facility on [DATE]. R16's Minimum Data Set (MDS) assessment, dated 3/1/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 was not cognitively impaired. On 6/5/23 at 9:08 AM, Surveyor interviewed R16 who stated R16 did not receive R16's AM medications until almost 12:00 PM over the weekend. R16…

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 monitoring of a high-risk medication for 1 Resident (R) (R191) of 16 residents reviewed. R191's medical record did not contain monitoring for side effects of oxycodone (an opioid medication). Findings include: The facility's Medication Monitoring policy, copyright 2023, contained the following information: This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences .Adverse Consequences is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or psychosocial status .6. Interventions shall be identified on the resident's comprehensive plan of care for the systematic monitoring of high-risk medication to facilitate early identification of adverse consequences. According to the Davis's Drug Guide for Nurses 18th edition copyright…

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.