Dove Healthcare - St Croix Falls

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (R) (R1) observed when cares were provided. Facility staff did not conduct appropriate hand hygiene when providing personal cares. Facility staff did not wear personal protective equipment (PPE) for R2 who is on Enhanced Barrier Precautions (EBP). This is evidenced by: Facility's policy titled Hand Hygiene dated 12/24, read in part, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table: .Between resident contacts. After handling contaminated objects, before applying and after removing personal protective equipment (PPE), including gloves. Before and after handling…

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 promptly notify and consult with a resident's physician when there was a significant change in a resident's clinical condition when blood sugar levels exceeded the threshold. This occurred for 1 of 3 residents (R) R4, reviewed for insulin use. This is evidenced by: The facility's STANDING ORDERS for SKILLED NURSING FACILITIES with the revised date of 2024, read in part, Diabetic Management .If DMII (diabetic mellitus type 2): Notify provider if two BG (blood glucose) results are <(less than) 70 or > (greater than) 400 in a 24-hour timeframe and/or change in condition; if no condition change, notify provider on the next business day . R4 was admitted to the facility on [DATE]. R4's current diagnoses include chronic kidney disease stage 3, congestive heart failure, type 2 diabetes mellitus, diabetic neuropathy, and diabetic retinopathy. Minimum Data Set (MDS) quarterly assessment, dated 10/04/24, documents R4's Brief Interview for Mental Status (BIMS)…

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 a resident who is unable to carry out daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Residents were not receiving regular weekly showers. This affects two of five residents reviewed, R1 and R7. Findings include: Example 1 The facility policy titled, Shower, reviewed in January 2025, states, It is the policy if this facility to assist resident with bathing to maintain proper hygiene, simulate circulation and help prevent skin issues as per current standards of practice . Residents will be provide showers as per request or as per facility scheduled protocols and based upon resident safety. R1 was admitted to the facility on [DATE] with the diagnoses of hypertension, diabetes mellitus, hyperlipidemia, arthritis, anxiety, and depression. R1's most recent Minimum Data Set (MDS), dated [DATE], indicated that R1 required substantial/maximal assistance - Helper does MORE THAN HALF 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 observations and interviews, the facility did not distribute and serve food with professional standards for food service safety. This has the potential to affect all 43 residents in the facility. Observations of handling ready to eat foods with contaminated gloves. Observed dirty air conditioner blowing on clean dishes. Dirty, unsanitary condition in dish room. Findings include: On 07/16/24 at 11:05 AM, Surveyor observed the dish room; there was a window air conditioner blowing on the clean dishes. Surveyor observed the blades of the air conditioner and there was a light gray colored dust on them. Surveyor also observed the exhaust fan above the dishwasher; there was a black colored fuzzy substance on the fan. Surveyor also observed a fan attached to the wall across from the dish machine with fuzzy, black in color substance on it. Also on the wall all around the fan were black fuzzy spots. On 07/16/24 at about 3:28 PM, Surveyor toured the dish room with Nutritional Services Director (NSD) K and asked NSD K if they thought the air conditioner was clean. NSD K indicated nope.…

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 establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 43 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to effect 43 of 43 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 during an outbreak. -Observations were made of the facility not implementing Enhanced Barrier Precautions (EBP) for 2 of 5 sampled residents on EBP. This is evidenced by: Example 1: The facility policy entitled, Water Management Program, which is not dated, states in part:…

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, the facility failed to ensure the Infection Preventionist (IP) is trained in special education and training in infection prevention and control. This has the potential to affect all 43 residents. This is evidenced by: Registered Nurse (RN) D was the facility's Infection Preventionist (IP) until 06/08/24. On 07/17/24 at 9:30 AM, Surveyor asked RN D if RN D had specialized training in Infection Control (IC) and prevention. RN D stated, No, I never did finish the infection control instructional class to become certified but that there was a corporation person for IC who oversaw the infection control program sometimes. Surveyor asked what that role consisted of for the corporation IC and RN indicated that corporation IC would come into facility sometimes and oversee some of the significant IC data but that it was inconsistent, and RN D would conduct surveillance as best as RN D could. Surveyor asked RN D how long has RN D been the IP at the facility. RN D stated, I started this role sometime in April/May of 2023 and continued in the IC/Director of Nursing (DON) role…

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, medical record review and facility document review, the facility did not have a comprehensive system for ensuring residents received influenza and/or pneumococcal immunizations, for 9 of 13 sampled residents, (R). (R40, R24, R11, R1, R2, R21, R42, R37, and R31) This is evidenced by: The CDC Influenza Vaccine Timing for Adults reads, in part: One dose of Influenza vaccine is recommended for adults each flu season . The CDC Pneumococcal Vaccine Timing for Adults reads, in part: Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose. Administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous dose of PPSV23 . Surveyor requested a list of current residents and their influenza and pneumococcal immunization dates. R40 was admitted on [DATE]. R40's immunization record stated that influenza and pneumococcal vaccinations were recommended. Facility did not have documentation that the facility offered or educated R40 of 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 staff interview and record review, the facility did not ensure 8 residents (R) of 13 sampled were offered a COVID-19 vaccine as indicated. (R40, R24, R1, R2, R21, R42, R37, and R31) This is evidenced by: The CDC COVID-19 vaccine Timing for Adults reads, in part: One dose of COVID-19 vaccination booster is recommended for adults every 6 months unless immunocompromised . Surveyor requested a list of current residents and their COVID-19 immunization dates. R40 was admitted on [DATE]. R40's immunization record stated that COVID-19 vaccinations were recommended. Facility did not have documentation that the facility offered or educated R40 of the COVID-19 vaccination recommendation. The facility did not have a declination form in R40's record of the COVID-19 vaccination being declined. R24 was re-admitted on [DATE]. R24's immunization record stated COVID-19 vaccination recommended. Facility did not have documentation that the facility offered or educated R24 of the COVID-19 vaccination. The facility did not…

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 failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in heath, mental, or psychosocial status in either life-threatening conditions or clinical complications. Staff did not contact physician when blood sugar levels exceeded the threshold that orders specified a physician to be contacted. This has the ability to effect 1 of 3 residents (R) R2 investigated for insulin use. Findings include: Record review of R2's orders included: HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro), Inject 9 unit subcutaneously three times a day for diabetes AND Inject 5 unit subcutaneously one time only for DM2 for 1 Day starting on 05/07/24. Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine), Inject 50 unit subcutaneously in the morning for Diabetes AND Inject 45 unit subcutaneously one time a day for dm starting on 05/19/24. Blood Glucose monitoring parameter. Hold insulin if BG is less than or equal to…

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 resident safety through assessment and that the environment remains as free of accident hazards as is possible for 2 of 2 residents (R301 and R25) reviewed. - R301 was evaluated by the facility to be a fall risk. R301 was observed self-ambulating to R301's car in the parking lot and driving to a neighboring community in R301's personal vehicle. -Facility staff did not follow the plan of care for safety with smoking for 1 of 3 residents (R25) reviewed for smoking. Findings include: R301 was admitted for short term rehabilitation on 07/03/24. R301's diagnoses include status post cerebral cyst removal surgery, schizophrenia, intervertebral disc disorder, bilateral arthritis of the knee, anxiety disorder, and spinal stenosis. R301's Minimum Data Set (MDS) assessment, completed on 07/08/24, confirmed R301 scored 14 during a Brief Interview for Mental Status (BIMS), indicating cognition intact. R301 requires partial to moderate assistance…

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 parenteral medications were administered consistent with professional standards of nursing practice for 1 of 1 (R24) resident reviewed. R24 was admitted to the facility on [DATE], with a Peripherally Inserted Central Catheter (PICC) line, which is a soft, thin, flexible tube in a vein used to administer IV medications and fluids. Staff did not complete appropriate assessment before administration of IV antibiotics. Staff were observed not applying alcohol-based connector locks after the administration of IV antibiotics. Findings include: The Association for Professionals in Infection Control and Epidemiology (APIC) guidelines, entitled Guide to Preventing Central Line-Associated Blood stream Infections, last reviewed 2015, states in part: Focus has shifted to use of disinfection caps that can be placed on the access port and maintain a level of disinfection. Various disinfection combinations are currently available, including…

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 failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility did not ensure that potentially hazardous foods were served at temperatures that would reduce the chance of illness for residents. This has the potential to affect all 47/47 residents residing in the facility. Findings include: The facility policy entitled, Record of Food Temperatures dated August 2022, states in part, 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit .7. when holding hot foods for service, food temperature should be measured when placing it on the steam table line . 9. Potentially hazardous food that is cooked and cooled must be reheated so that all parts of the food reach and internal temperature of 165 degrees F for at least 15 seconds before holding for hot service. On 05/14/24 at 11:55 AM, Surveyor entered the kitchen to observe meal distribution. Prior to serving the food to residents, Surveyor did not observe any 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure 1 of 12 nurses reviewed had the proper licensure in accordance with Wisconsin state law licensing requirements. This had the potential to affect all 47 residents in the facility. This is evidenced by: On [DATE], Surveyor requested and received licensure information for 12 nurses at the facility. Upon reviewing nursing licensures, Surveyor reviewed documentation for Licensed Practical Nurse (LPN) N. The facility did not have documentation of a Wisconsin license for LPN N. The facility did provide documentation for ACT 10 (temporary licensure), which stated LPN N started employment at the facility on [DATE]. The form was not signed by the Director of Nursing (DON) B until [DATE]. ACT 10 expired [DATE]. LPN N has worked at the facility full-time since [DATE] without an active Wisconsin nursing license and works througout the building. On [DATE] at 8:41 a.m., Surveyor contacted Department of Safety and Professional Services (DSPS). Surveyor spoke 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 staff interviews, the facility did not provide pharmaceutical services, including services that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of 4 of 4 residents reviewed for medication administration (R) (R1, R2, R5, R6). This is evidenced by: Example 1 On 05/14/24, Surveyor reviewed R1's medical record. R1 was readmitted to the facility on [DATE] at 1:50 p.m., with diagnoses including acute embolism and thrombosis of unspecified deep veins of right lower extremity, acute on chronic congestive heart failure with reduced ejection fraction, and right heart dysfunction, type 2 diabetes mellitus with hypoglycemia without coma, type 2 diabetes mellitus with diabetic neuropathy-unspecified, other pulmonary embolism without acute cor pulmonale, presence of other vascular implants and grafts, presence of aortocoronary bypass graft, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. 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.

Based on record review and interview, the facility did not provide care and treatment in accordance with professional standards of practice related to resident assessment after a fall incident for 1 resident (R) (R7) of 3 residents reviewed for falls. R7 sustained a fall, and when reported, the facility's licensed nursing staff did not assess R7. This is evidenced by: On 05/14/24, Surveyor reviewed R7's medical record concerning a fall. R7's nurse's notes state on 3/10/2024 at 1:14 p.m., R7 verbalized to staff that R7 fell. R7 complained of left hip pain to the nurse on 03/10/24. R7 said R7 fell yesterday, 03/09/24. R7 said R7 was transferring from the wheelchair to the bed. R7 went to grab the arm of the wheelchair and fell to the ground on R7's left side. R7 stated, The blonde girl went and got the cherry picker, then hooked R7 up, and then staff lifted R7 back to the wheelchair. Nursing took R7's vital signs and notified Director of Nursing (DON) B. R7 rated pain level at 5 out of 10. Nursing gave R7 Tylenol, which was effective in managing pain. Nursing notified R7's spouse 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility did not ensure the resident environment remained as free of accident hazards as possible. The facility did not assess the resident's ability to use cigarettes after determining the resident used nicotine products. This occurred for 1 of 3 residents (R) 7 reviewed for assessments related to nicotine use. This is evidenced by: The facility policy, entitled Smoking - Residents & Visitors which was not dated, did not have any information regarding assessing residents who chose to smoke while attending the facility. Surveyor requested a policy for nicotine use. Facility had no policy related to nicotine use. On 05/14/24 at 5:30 PM, Surveyor observed R7 smoking out in the parking lot as they were leaving for the day. R7 was able to smoke without any concerns to safety of the resident. On 05/15/24 at 11:40 AM, Surveyor entered R7's room to interview regarding staffing and shower concerns and noted that R7 had a container of [NAME] wintergreen chewing…

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 report a reasonable suspicion of a crime to law enforcement or report an allegation of misappropriation of narcotic medications to the state agency for 5 of 8 residents (R16, R14, R8, R7, and R13) reviewed. This is evidenced by: The facility policy, entitled Controlled Substance Administration and Accountability, revised February 01, 2024, states: 10. Discrepancy Resolution: a. Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered. c. Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access. e. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy 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, interview and record review, the facility did not ensure to complete thorough investigations for misappropriation of narcotics form pharmacy emergency kit and Residents (R7 and R13). The facility did not complete a thorough investigation for potential abuse or neglect for R1. This occurred for 3 of 9 residents reviewed for investigations. This is evidenced by: Example 1 The facility policy Controlled Substance Administration and Accountability, revised February 01, 2024, states .10. Discrepancy Resolution: a. Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it is discovered. c. Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access. e. Any discrepancies which cannot be resolved must be reported immediately as follows: i. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy,…

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 proper reconciliation, disposition, or accurate records of controlled medications for 7 of 8 residents (R) and from emergency kit (E-KIT). (R16, R14, R8, R3, R15, R7, and R13) Findings include: The facility policy, entitled Controlled Substance Administration and Accountability, revised February 01, 2024, states: 2. Storage and Security: b. Areas without automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for 24-hour recording of controlled substance use. C. Patient-specific controlled substances are stored under double lock until administered to the patient. 3. Ordering and Receiving Controlled Substances: b. For patient care areas daily orders for the stock narcotics are filled out by the charge nurse and the amount on hand is checked against the amount used daily from the documentation records, the order form is completed and sent to pharmacy making sure it contains unit/wing ordering the medications, signature of person making the request,…

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 serve palatable hot foods for 7 of 43 residents residing in the facility. (R12, R7, R8, R6, R4, R2, and R13). This is evidenced by: On 02/22/24 at 9:30 AM, staff reported residents eat meals in their rooms, due to a COVID outbreak. R1, R3, and R5 require assistance with eating meals and may eat in the dining room with staff assist. On 02/22/24 at 9:40 AM, Surveyor reviewed Resident Council minutes for November, December, and January and noted the following: -November food concerns: Noodles are crunchy over overcooked. -December food concerns: Pancakes not cooked in the middle. Noodles are dry and need more sauce. -January food concerns: Pork is too tough, too many noodles. On 02/22/24 at 9:49 AM, Surveyor reviewed facility grievances related to food and noted the following: -02/05/24, R12 reported every tray of food he receives is cold and undercooked. Grievance was brought to dietician. -02/14/24, R12 reported never receiving hot meals, all meals are cold and sit on carts in the hallway for extended periods 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure activities of daily living (ADLs) of meal set-up, repositioning, incontinence cares, bed baths, and obtaining body weight were provided for 2 of 11 residents (R9 and R13) reviewed. This is evidenced by: Example 1 R9 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), trochanteric bursitis bilaterally, muscle weakness, morbid severe obesity, and depressive disorder. R9's minimum data set (MDS) assessment, completed on 01/17/24, confirmed R9 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating cognitively intact. R9 makes his own healthcare decisions. R9 is incontinent of urine and frequently incontinent of bowels. R9 requires set-up assistance with eating and oral hygiene. R9 is dependent on staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R9 is at risk for pressure injuries. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record reviews, the facility staff failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 3 (R8, R12, R9) of 7 residents (R) reviewed for pain. This is evidenced by the following: Example 1 R8 was admitted to the facility on [DATE], with diagnoses including pressure ulcer of sacral region, trochanteric bursitis bilaterally, type 2 diabetes mellitus, dysphagia, osteomyelitis of vertebra, reduced mobility, and anemia. R8's Minimum Data Set (MDS) assessment, completed on 01/02/24, confirmed R8 scored 9/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognition impairment. R8 is dependent on staff for personal hygiene, showering/bathing, toileting, transferring, dressing upper and lower body, and putting on/taking off footwear. Surveyor reviewed no initial admission pain assessment for R8 completed. R8's pain assessment completed 02/23/23, confirmed R8 is at high…

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 ensure 1 of 5 nurses reviewed had the proper licensure in accordance with Wisconsin state law licensing requirements. This had the potential to affect all 44 residents in the facility. Licensed Practical Nurse (LPN) C, who is a current employee, has worked at the facility as an LPN since 4/17/23 to date of survey without a Wisconsin nursing license. Findings include: On 11/06/23 at 10:30 AM, Surveyor requested proof of Wisconsin nursing licensure for 5 nurses. On 11/06/23 at 11:00 AM, Nursing Home Administrator (NHA) A provided documentation on the licensure of the 5 nurses. LPN C's documentation showed a valid Minnesota nursing license. Minnesota is not a compact licensure state with Wisconsin. LPN C does not have a Wisconsin nursing license. LPN C has worked at the facility as a night shift nurse since 04/17/23 without a valid Wisconsin nursing license. On 11/06/23, Surveyor interviewed NHA A and Director of Nursing (DON) B regarding LPN C not having a valid Wisconsin nursing license. NHA A and DON B stated that they had…

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 services were provided by individuals who had proper certification, skills, experience, and knowledge to do a particular task for 1 of 4 (R3) residents reviewed. Findings include: R3 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's disease, dementia, mood disturbance and anxiety. R3's Minimum Data Set (MDS), significant change, dated 08/16/23, indicated that R3 has a Brief Interview for Mental Status (BIMS) score of 03 (severe cognitive impairment) and is on hospice care. R3's care plan, dated 08/21/23, with target date of 09/05/23, states, The resident has a mood problem related to dementia with behavioral disturbance and observe for signs and symptoms of mania or hypomania, racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, agitation or hyperactivity. R3's medication administration record shows that R3 has Morphine…

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, prepared, distributed and served in accordance with professional standards for food service safety. This had the potential to affect all 37 residents in the facility. Facility did not ensure milk was kept at a safe temperature of 41 degrees or lower during lunch service on 7/10/23. Facility did not ensure refrigerator and freezer in the TCU kitchen were monitored for appropriate temperatures and did not ensure resident foods brought in from outside were labeled with date opened and discarded when expired. Findings include: According to the 2022 U.S. Food and Drug Administration Food Code, the safe temperature for holding cold foods is 41 degrees Fahrenheit (F) or less. Facility Policy entitled, Resident Personal Refrigerator, last reviewed 02/27/20, stated in part, All food brought in from outside source, i.e.: residents, family, visitors, etc. will be stored in a safe manner and used within appropriate time frame to maintain food quality and safety .Procedure: 1. All foods brought into…

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

Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections during 4 observations. Staff did not assist residents (R) with hand hygiene prior to meals in the main dining room during observations of lunch meal on 07/10/23 and breakfast meal on 07/11/23. This affected R13, R4, R35, R24, R11, R20, R19, R10, R239, R1, R33, R18, R28, R6, R25, R17, R13, R21, R27, and R12. Staff did not perform hand hygiene and did not sanitize mechanical lifts before or after transferring. This affected 2 of 2 residents (R26 and R4). Registered Nurse (RN) S cut vitamin medication into half with a pill splitter, placed pill splitter back into medication cart without properly disinfecting medication administration equipment, then administered medication to R7-A. This affected 1 of 1 residents during medication administration task. RN S placed bare fingers into stocked Senna Plus bottle and administered two…

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 record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 3 of 8 staff reviewed. This had the potential to affect all residents. Facility did not complete criminal background checks every four years for 3 of 8 employees reviewed. Findings include: Facility policy entitled, Abuse, Neglect and Exploitation, dated 08/22/22, stated in part, I. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property . According to the Wisconsin Caregiver Program Manual, dated 02/2016, .Since October 1, 1998, entities have been required to complete caregiver background checks on all new caregivers. After the initial background check at the time of employment or contracting, entities must conduct new caregiver background checks at least every four years or at any time within that period that an entity has reason to believe new checks should be obtained…

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 complete the required Preadmission Screen and Resident Review (PASRR) screen for 2 of 3 residents reviewed, (R17, R28). R17 was admitted to the facility and had a PASRR screen which indicated that they would remain in the facility for under 30 days. When this resident's stay exceeded 30 days, a new PASRR screen was not completed. R28 was admitted to the facility and had a PASRR screen which indicated that they would remain in the facility for under 30 days. When this resident's stay exceeded 30 days, a new PASRR screen was not completed. This is evidenced by: Example 1 R17 was admitted to the facility and has diagnoses including adjustment disorder, post-traumatic stress disorder, and depression, for which the resident takes Wellbutrin. R17's medical record included a PASRR level 1 screen which was completed on 03/29/22. This level 1 screen indicated that R17 has a major mental illness and indicates that R17 takes medications for that mental illness. The form also indicates that R17 is being admitted under a hospital…

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 develop a medical care plan for 1 of 13 resident (R12) care plans reviewed. The facility did not develop a diabetic plan of care for R12. This is evidenced by: R12 was admitted to the facility on [DATE] and has diagnosis that include type 2 diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and major depressive disorder. Surveyor reviewed R12's comprehensive care plan and identified a diabetic plan of care was not developed. On 07/12/23 at 10:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA) R and asked how they know if a resident is a diabetic. CNA R indicated that it is on the resident's [NAME]. Surveyor asked CNA R when doing bathing do you clip nails of someone that is diabetic. CNA R indicated no that the nurses do that. On 07/12/23 at 11:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C who is also the regional travel supervisor and asked where info is pulled from on the [NAME] that the CNAs refer to…

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 revise care plans to include non-pharmacological interventions for 3 of 5 sampled residents (R17, R35, and R28) for psychotropic medications. R17's care plan was not updated to identify non-pharmacological individualized interventions for insomnia and depression related to current use medications of Trazadone and Wellbutrin. R35's care plan was not updated to identify non-pharmacological individualized interventions for depression related to current use medication of Wellbutrin. R28's care plans was not updated to include non-pharmacological interventions for generalized anxiety disorder and major depressive disorder, severe with psychotic symptoms. This is evidenced by: Example 1 R17 was admitted on [DATE] with diagnoses which include, in part, Parkinson's disease, and post traumatic disorder. R17's Minimum Data Set (MDS) dated [DATE] indicates Brief Interview for Mental Status (BIMS) of 15, which means R17 is cognitively intact and Patient Health…

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 record review and interviews, the facility did not ensure that 2 (R26 and R33) of 4 sampled residents who are unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. R26 and R33 did not receive a weekly shower. Findings include: The facility policy entitled, Resident Showers, dated 08/22/22, states: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standard of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Example 1 R26 was admitted to facility on 03/16/23 and has diagnoses that include muscle weakness, mild cognitive impairment, and type 2 diabetes. R26's quarterly Minimum Data Set (MDS) assessment, dated 06/09/23, indicated that R26 requires physical help in part of bathing activity with two-personal physical support provided and that no refusal of care behaviors was exhibited. R26's plan…

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 record review, observation and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (R4). Facility staff did not follow R4's plan of care to ensure fall interventions were in place. Findings include: Facility Fall Risk Assessment, dated 8/22/22, states: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control and provides the supervision and assistive devices to each resident to prevent avoidable accidents. R4 was admitted to facility on 10/14/2019, and has diagnoses that include history of falls, mild cognitive impairment, vascular Parkinsonism. R4's quarterly Minimum Data Set (MDS) Assessment, dated 6/6/23, indicated a Brief Interview for Mental Status (BIMS) score of 7, requires extensive assistance for transfers with one-person physical assist and had 2 or more falls since previous MDS. R4's care plan indicates R4 is at risk for falls related to de-conditioning, gait/balance problems, weakness,…

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 record review and interview, the facility did not ensure that 1 of 5 staff reviewed for verification of a current Nurse Aide Registry were on the Wisconsin registry before starting work in the facility. Certified Nursing Assistant (CNA) H was not on the Wisconsin Nurse Aide Registry and was working in the facility at the time of the discovery. Findings include: On 07/10/23, Surveyor reviewed CNA certifications for a sample of 5 CNAs. CNA H was hired on 07/05/23. Nursing Home Administrator (NHA) A provided a state of Minnesota CNA registry certificate for CNA H. No Wisconsin CNA registry information was provided. On 07/10/23 at 4:10 PM, Surveyor interviewed NHA A about the missing Wisconsin CNA Registry for CNA H. NHA A stated CNA H had applied for the Wisconsin registry on 07/05/23. NHA A provided a copy of the Wisconsin registry application. NHA A thought CNA H could work in the facility while the application was pending. According to the Wisconsin Nurse Aide Training and Registry team, nurse aides must be listed on the Wisconsin Nurse Aide Registry in order to be employed…

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

Based on observation and interview the facility did not provide pharmaceutical services, including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 2 of 2 medication rooms reviewed, or ensure accurate administering of insulin. The facility did not ensure destruction of medication occurred timely after Resident (R9 and R31) were discharged from the facility. The facility did not ensure safe and secure storage for controlled substances and emergency/contingency medications. Licensed Practical Nurse (LPN) V administered insulin medication without checking the expiration date for R2 and R17. Findings include: Example 1 Emergency pharmacy service and Emergency Kit policy with revise date October 2022 under procedure section letter O it states in part, Facility staff will check the emergency medication kit(s) for the presence of an expiration date and to ensure kit is properly stored, locked, and in date at least monthly. On 07/11/23 at 8:30 AM, Surveyor observed medication storage…

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 psychotropic drugs are not given unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (R17) reviewed. The facility did not complete a sleep assessment to determine adequate indication for use of an antidepressant medication (Trazadone) for R17 to promote sleep. This is evidenced by: R17 was admitted on [DATE] with diagnoses which include, in part, Parkinson's disease, and post traumatic disorder. R17's Minimum Data Set (MDS) dated [DATE] indicates Brief Interview for Mental Status (BIMS) of 15, which means R17 is cognitively intact and Patient Health Questioner (PHQ-P) with score of 8, which means mild depression severity. R17's care plan, dated 06/02/23, with a target date of 09/30/23 states, in part: Administer antidepressant medication (Trazadone) related to sleep disturbances as ordered, monitor/document PRN adverse reactions to antidepressant…

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 a medication error rate of 5% or less for 2 of 5 residents (R2 and R17) observed for medication pass. The facility had 48 opportunities and 3 medication errors resulting in a 6.25% error rate. Licensed Practical Nurse (LPN) V administered insulin medication without checking the expiration date for R2 and R17. This is evidenced by: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Surveyor reviewed policy Administering Medications which states in part, under number 12 bulletin point, The expiration/beyond use date on the medication is checked prior to administering . Number 17 bulletin point also states in part, Insulin pens are clearly labeled with residents name, and other identifying information prior to administering . On 07/11/23 at 7:19 AM, Surveyor observed medication administration with LPN V. LPN V gave R2 Lantus insulin pen 32 units subcutaneous in the abdomen without verifying expiration…

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.