Sauk Co Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 residents (R2) reviewed for abuse.Facility became aware of an injury of unknown origin on 12/19/25 when R2 was sent to the emergency department and was found to have a closed nondisplaced fracture of the left pinky finger. The facility failed to report it to the state within the required timeframe.Evidenced by:The facility policy entitled Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 12/2025, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from Abuse. Sauk County Health Care Center will take all reasonable measures to ensure resident safety and security and will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 1 of 3 Residents reviewed (R2).Facility became aware of an injury of unknown origin on 12/19/25 when R2 was sent to the emergency department and was found to have a closed nondisplaced fracture of the left pinky finger. The facility failed to conduct and complete a thorough investigation.Evidenced by:The facility policy entitled Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 12/2025, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from Abuse. Sauk County Health Care Center will take all reasonable measures to ensure resident safety and security and will promptly investigate all reports/allegations of resident rights violations, abuse, neglect,…

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 that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 3 residents (R1 and R2) reviewed for abuse. Facility became aware of an abuse allegation on 10/4/25 at 7:41 PM involving R1 and R2 The facility did not report the allegation to the State Agency. Evidenced by: The facility policy entitled, Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 10/2024, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, exploitation, corporal punishment or involuntary seclusion.Definitions: Definitions of Abuse and Neglect: .i. Verbal abuse is defined as the use of oral,…

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 failed to thoroughly investigate an accusation of verbal abuse for 2 of 3 residents (R1 & R2) reviewed for abuse.Facility became aware of an abuse allegation on 10/4/25 regarding R1 and R2. The facility did not conduct a thorough investigation or put protections in place during the investigation. Evidenced by:The facility policy entitled, Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 10/2024, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, exploitation, corporal punishment or involuntary seclusion.Definitions: Definitions of Abuse and Neglect: .i. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. Examples of verbal abuse include, but are not limited to: threats 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, interview, and record review, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable for 1 of 2 medication rooms and 2 of 5 medication carts reviewed for compliance. Surveyor observed the following: -R25's PRN (as needed) Loperamide (27 capsules) expired 12/24. -R19's PRN Loperamide (4 capsules) expired 12/24. -R6's escitalopram (1 tablet) card expired 9/24. -3 boxes of blood glucose control solutions expired (7/27/23 & 3/1/25). -R9's Naproxen (7 tablets) PRN card expired 11/24. -6 stock insulin pens were expired: -1 Semglee expired 6/24. -2 Tresiba expired 12/31/23 & 11/30/24. -3 Basaglar expired 8/17/24 and 2 on 4/04/24. -Stock supply of Promethazine suppositories (6 suppositories) expired 10/24. Evidenced by: The facility policy entitled, Medication Storage Policy, undated, states, in part: .Policy: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Procedure: . D. 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.

Based on interview and record review, the facility did not implement policies and procedures to prohibit and prevent abuse for 1 of 8 staff reviewed for caregiver background checks. LPN G (Licensed Practical Nurse) was hired on 12/3/24 and had lived in one other state within the last three years. LPN G's background check information did not contain an out-of-state criminal background check. This is evidenced by: The facility's Prevention/Reduction of Resident Abuse, Neglect, Exploitation or Misappropriation of Property policy, revised 05/19 and reviewed 10/24, indicates in part: Employee Screening and Training .d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. The facility's Care Giver Background Investigations policy, reviewed/revised on 03/21/14, indicates in part: As applicable, other documentation will be obtained by the entity when information is needed to complete the background check, such as out of state's conviction records when a 'caregiver' has lived out of the state 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, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (R25) reviewed for catheter care out of total sample of 17. Staff did not perform appropriate hand hygiene per Standards of Practice while providing catheter care. Evidenced by: The facility policy entitled. Hand Washing, dated 3/19/24, states, in part: . Purpose: -To cleanse hands to prevent the spread of potentially deadly infections -To provide a clean and healthy environment for residents, staff, and visitors -To reduce the risk to the healthcare provider of colonization or infections acquired from a resident Hand hygiene continues to be the primary means of preventing the transmission of infection. Policy: It is the policy of this facility that hand hygiene (HH) (e.g. hand washing and/or Alcohol-based hand rub (ABHR), also known as Alcohol-based hand sanitizer (ABHS), is to be performed consistent 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 observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 residents (R30 & R9) included in the medication pass task, which resulted in an error rate of 6.9%. R30 did not receive her ordered senna at the ordered time. R9 did not receive her ordered aspirin at the ordered time. Evidenced by: The facility policy entitled, Medication Pass, dated 2/2016, states, in part: .Policy: It is the policy of the [Facility name] that medications prescribed by the Physician will be administered accurately and timely. Procedure: .2. Read and compare the label on the drug with the MAR (Medication Administration Record) at least three (3) times- before, during and after preparing the drug .16. Be sure that you have the- A. Right Drug B. Right Dose C. Right Route D. Right Time E. Right Resident . Example 1: R30 was admitted to the facility on [DATE] and has diagnoses that include…

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 that each resident's drug regimen was adequately monitored and that the drug regimen was free from adverse consequences for 1 of 1 resident (R2) reviewed for adequate monitoring. R2 has a diagnosis of Atrial Fibrillation (an irregular heartbeat, that occurs when the upper chambers of the heart beat rapidly and irregularly) and receives Coumadin (a blood thinner). R2 was prescribed Bactrim on 10/1/24. Antibiotics can potentiate the effect of Warfarin (Coumadin). The facility did not complete monitoring for symptoms of drug interactions. R2 was sent to the hospital after a fall and was found to have a supratherapeutic (high) INR (international normalized ratio, a lab that measures how long it takes the blood to clot) of 4.5. The therapeutic range for INR is 2-3. This is evidenced by: The facility's policy titled Warfarin (Coumadin) Monitoring states in part; Purpose: To assure resident safety with a goal to maintain INR and keeping within residents…

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, the facility did not ensure that 4 of 4 sampled residents (R1, R12, R13, and R35) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to provide diabetic foot checks daily in accordance with current standards of practice. The facility did not have a policy reflecting the current standards of practice related to diabetic foot checks. Evidenced by: Facility policy, entitled Skin Integrity-Foot Care, reviewed 4/2024, does not reflect current standards of practice related to daily diabetic foot checks completed by a nurse or someone with education to perform assessments. Per the American Medical Directors Association - The Society for Post-Acute and Long-Term Care Medicine. Pressure Ulcers. Clinical Practice Guideline, dated 12/9/14, includes, in part: http://www.amda.com/tools/guideline.cfm#pressureulcer .to the extent feasible, caregivers should educate patients about daily foot care .Treatment of foot problems 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 and interviews, the facility failed to serve food at an appetizing temperature. This has the potential to affect 2 of 17 sampled Residents (R32 and R3) and 2 of 3 supplemental Residents (R36 and R20). R3, R32, R36, and R20 voiced concerns that hot food was not always served hot and cold food was not served cold. 1 of the 2 test trays temped failed to meet appropriate temperatures. Evidenced by: The facility policy, Food Temperatures, with a revised date of, 4/2024, states, in part; .All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F All cold food items must be maintained at served at a temperature of 41 F or below Example 1 On 4/18/24 at 8:01 AM, the kitchen delivered breakfast on B Hallway. Surveyor requested the last tray on the cart. Dietary Aide provided Surveyor the last tray. The tray had French toast sticks, bacon, yogurt, and crushed strawberries. French toast sticks temped at 102.3 F and were hard. No concerns…

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.