Marquardt Memorial Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R68) of 6 sampled residents.During the provision of incontinence care for R68, Certified Nursing Assistant (CNA)-F did not complete hand hygiene after removing soiled gloves.During the provision of incontinence care for R68, CNA-G did not wear a gown, appropriately change gloves, or complete hand hygiene after removing soiled gloves. Findings include: The facility's Hand Hygiene policy, revised 12/5/24, indicates: Hand hygiene should be completed before moving from work on a soiled body site to a clean body site on the same resident, after contact with bodily fluids, and immediately after glove removal. The facility's Enhanced Barrier Precautions (EBP) policy, revised 2/6/25, indicates: For residents for whom EBP is indicated, a gown and gloves should be worn when completing high-contact…

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, resident, and resident representative interview and record review, the facility did not ensure grievances were thoroughly investigated and resolved for 3 residents (R) (R1, R4, and R5) of 4 sampled residents.Family Member (FM)-I filed a grievance on behalf of R1 on 1/7/26 that included concerns about a missed appointment, wound care, and assistance with cares. The facility did not investigate or provide resolution for the grievance. R4 reported in September 2025 that R4 did not receive scheduled showers. The facility did not document, investigate, or provide resolution for the grienvance.R5 reported to staff that Registered Nurse (RN)-R swore at R5. Staff reported to the concern to a supervisor; however, the facility did not file a grievance or follow-up on the concern. Findings include: The facility's Policy and Procedure for Grievances indicates: .The facility fosters an environment of direct communication, prompt resolution, and continuous process improvement. Grievances may be brought to any…

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, resident, and resident representative interview and record review, the facility did not ensure scheduled showers/baths were provided for 3 residents (R) (R4, R1, and R3) of 13 sampled residents.R4 was scheduled for a weekly shower on Tuesday evening. R4 did not receive showers as scheduled.R1 did not receive a shower while at the facility because the facility did not have a functioning bariatric shower chair.R3 did not receive weekly showers as scheduled. In addition, R3's preference to receive a shower instead of a bed bath was not consistently honored. The facility's undated Standard Activities of Daily Living (ADL) Protocol indicates: ADLS: .bathing .Individual will perform ADLs .with or without staff assist. Certified Nursing Assistant (CNA): Offer individual choices with care routines .Offer weekly bath or shower per individual preference . 1. On 2/4/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis…

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 the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R1) of 3 sampled residents.R1 had an unstageable deep tissue injury that was treated without a physician order. In addition, R1 had a stage 2 pressure injury that was not identified in the facility and was discovered while R1 was at a medical appointment. Findings include: The facility's Pressure Injury Prevention and Managing Skin Integrity policy and procedure, dated 5/8/25, indicates: Prevention measures are put in place to reduce the occurrence of pressure injuries .1. Risk Assessment: a. Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. b. Re-evaluation: Braden Scale will be completed upon change of condition and quarterly. c. Based on the individual's Braden Scale score, pressure reduction…

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 1 resident (R) (R1) of 1 sampled resident received timely placement of a suprapubic catheter (a tube inserted through a small incision in the lower abdomen directly into the bladder to drain urine). R1 did not have transportation from the facility to a medical appointment on 12/31/25 that was scheduled to remove R1's indwelling urinary catheter (a flexible tube inserted through the urethra into the bladder to continuously drain urine into an external bag) and replace it with a suprapubic catheter. R1 scheduled a new appointment for 1/5/26 for placement of the suprapubic catheter. Findings include: On 2/2/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including complete paraplegia, diabetes mellitus type 2, anxiety, obesity class 3, neuromuscular dysfunction of bladder (loss of normal bladder control due to nerve damage), and neurogenic bowel. R1's most recent Minimum Data Set (MDS)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R5) of 3 sampled residents received oxygen therapy.R5's oxygen tubing was changed on 1/9/26. Following the change, staff did not turn R5's oxygen back on. As a result, R5 was without supplemental oxygen for approximately 6 hours. Findings include:The facility's undated Standard Respiratory Protocol indicates: Problem: Impaired or potential impairment of gas exchange related to chronic respiratory disease. Goal: Individual will have an effective respiratory rate, depth, and rhythm. Registered Nurse: .Apply oxygen, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) as ordered.On 2/4/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, morbid obesity, alveolar hypoventilation, peripheral vascular disease, history of pulmonary embolism, and dependence on supplemental oxygen. R5'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 staff and resident interview and record review, the facility did not ensure an opportunity to create a Power of Attorney (POA) document or a document that designated an alternate decision maker in the case of incapacity was provided for 1 resident (R) (R1) of 5 sampled residents.The facility did not offer R1 an opportunity to create a POA document or any document to designate a decision maker if R1 became incapacitated.Findings include:The facility's Individual Advanced Care Planning policy, dated 2/21/24, indicates: .A. Upon admission: .2. Per the Patient Self Determination Act, information about Wisconsin advanced health care directives will be provided to individuals upon their admission to the facility .B. Upon admission/re-admission, change in condition, and at care conferences: 1. Advanced care planning will be discussed and/or verified. 2. The resources available in the skilled nursing facility to treat symptoms and conditions will be discussed as appropriate.On 10/6/25, Surveyor reviewed 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 staff and resident 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 1 sampled resident. R1 reported to staff that another staff call R1 stupid. The allegation of abuse was not reported to the SA.Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program policy indicates: It is the poliy of the facility that each resident will be free from abuse .The Executive Director or designee will report abuse to the State Agency per state and federal requirements .G. Reporting and Response: .The facility will ensure that all alleged violations involving abuse .are reported 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R1) of 1 sampled resident observed during the provision of care. Licensed Practical Nurse (LPN)-C and Certified Nursing Assistant (CNA)-D did not wear appropriate personal protective equipment (PPE) during wound care for R1. In addition, LPN-C did not complete proper hand hygiene or ensure a treatment cart and supplies were free from infectious agents during and after the provision of wound care. Findings include: The facility's Enhanced Barrier Precautions policy and procedure, dated 2/6/25, indicates: The organization will promote decreased transmission of Centers for Disease Prevention and Control (CDC)-targeted and epidemiologically important multidrug-resistant organisms (MDROs) by utilizing Enhanced Barrier Precautions (EBP) .a. The infection Prevention and Control Program…

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 observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 1 resident (R4) reviewed for transmission-based precautions. R4 had a sign posted on his door that he was under isolation for droplet precautions; however, a staff member entered R4's room without following the droplet precaution protocol, wearing the appropriate PPE (Personal Protective Equipment) or performing hand hygiene per standards of practice. This is evidenced by: Facility policy, titled Infection Prevention and Control Program dated 6/14/17, with last review date of 5/8/25, states, in part: Policy: To prevent the development and transmission of disease and infection, the organization will follow the Infection Prevention and Control Program procedures below. Procedure: 1. Prevention 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 interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect 9 residents (R5, R6, R7, R8, R9, R10, R11, R12, and R13) currently residing in the facility with a substance use disorder (SUD) diagnosis. The facility assessment must reflect the resident population and resources needed to care for this population. Nine residents had a diagnosis of SUD however the facility did not address the resources needed to care for these residents. R5 has a diagnosis of alcohol abuse. R6 has a diagnosis of alochol dependence with alcohol induced persisting dementia. R7 has a diagnosis of alochol abuse. R8 has a diagnosis of alcohol dependence. R9 has a diagnosis of alcohol dependence. R10 has a diagnosis of alcohol dependence. R11 has a diagnosis of alcohol abuse. R12 has a diagnosis of alcohol abuse. R13 has a diagnosis of cannabis use. 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 provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address substance use disorder (SUD) for 3 of 3 residents (R1, R4, and R5) reviewed for SUDs. R1 had cocaine use, regularly drank alcohol while in the facility and had a history of cannabis use. R1 did not have an assessment or comprehensive person-centered care plan for R1's SUD and did not have timely interventions for R1's SUD. R5 regularly drank alcohol while in the facility and did not have a care plan with interventions for SUD. R4 did not have a care plan in place for his diagnosis of alcohol use. This is evidenced by: The facility policy titled Comprehensive Person-Centered Care Plan, dated [DATE], states in full: I. Policy: The Comprehensive Person-Centered Care Plan will reflect the individual's needs and preferences to facilitate…

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 food was prepared and served in a sanitary manner. -Proper dishwashing rinse cycle temperatures were not obtained on the dish washing machine gauge or the manual gauge that was run though the dishwashing machine. There was no evidence or observations that sanitizing temperature was reached by the dishmachine and the dishmachine was observed to not properly sanitize the dishware through the high temperature cycle. -Cook-R was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat. [NAME] was observed not changing gloves and washing hands after touching non-sanitized food surfaces. This practice has the potential to affect 76 of 76 residents residing in the facility. Findings include: 1.) The Facility Policy and Procedure titled, Manual Dishwashing with no dates, documents: Policy: All flatware, serving dishes, and Cookware 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 observation, record review and staff interviews, the facility did not ensure 1 out of 1 residents ( R27) reviewed for the use of a physical restraint, conducted a comprehensive assessment and developed a plan of care for the continued use of the physical restraint. R27 has an abdominal binder in place at all times which cannot be removed easily by R27 and restricts R27's freedom of movement or normal access to her body. The facility did not provide evidence that the use of the abdominal restraint is the least restrictive alternative and did not ensure that it was used for the least amount of time and did not document on-going re-evaluation of the need for the abdominal binder. Findings include: R27 was originally admitted to the facility on [DATE] with diagnosis that included Spastic Quadriplegic Cerebral Palsy (CP), Developmental Disorder of speech and language, severe intellectual disabilities, and Dysphasia. R27 has a gastronomy tube (g-tube) in place to assist in meeting nutritional needs because…

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 2.) R35 was admitted to the facility on [DATE] from the hospital with a primary diagnosis of alcohol dependence with alcohol-induced persisting dementia; and other diagnoses which include, in part, encounter for palliative care, epilepsy, and anxiety disorder. R35's quarterly Minimum Data Set (MDS) with an assessment reference date of 9/9/24 indicated R35 had a Brief Interview for Mental Status score of 13 (fully intact memory). R35 makes self understood and understands others. No behaviors were noted during the look back period. R35's upper extremity has an impairment on one side, the lower extremities have no impairment. R35 is always continent of bowel and bladder. R35 has the following care plan for falls: The resident is Moderate risk for falls r/t Deconditioning, Gait/balance problems, Dementia, Hx falls. Date Initiated: 05/01/2023 Revision on: 07/24/2023 Goal: o Risk of falls/falls with injury will be minimized Date Initiated: 05/01/2023 Revision on: 09/03/2024 Target Date: 12/08/2024 Interventions: o…

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 interviews and record review the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, including the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 of 1 (R24) residents reviewed for dialysis. The facility did not implement interventions to assess and document care of R24's Arteriorvenous (AV) fistula including auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow. Findings include: R24 admitted to the facility on [DATE] and has diagnoses that include End Stage Renal Disease, dependence on renal dialysis, Peripheral Vascular Disease, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Atherosclerotic Heart Disease, Chronic Congestive Heart Failure and Atrial Fibrillation. The facility Dialysis Policy and Procedure reviewed 7/13/21 documents (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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure medical records contained documentation related to Pneumococcal immunizations for 1 (R67) of 5 residents reviewed for immunizations. R67's medical record does not contain any documentation as to whether R67 was offered, received, or declined the Pneumococcal immunization. Findings include: The facility policy entitled, Infection Control-Individual Immunizations, with a review date of 9/20/2023, documents, in part: Prophylactic immunizations will be offered to individuals to promote the absence of Health Care Acquired Infections . Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated and administer immunizations as ordered. Individual will be offered immunizations based upon the Center for Disease Control (CDC) recommendations and guidelines and as prescribed by their PCP. Other prophylactic treatments or immunizations will be offered to individuals per medical director…

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 medical records contained documentation related to COVID-19 immunizations for 1 (R67) of 5 residents reviewed for immunizations. R67's medical record does not contain any documentation as to whether R67 was offered, received, or declined the COVID-19 immunization. Findings include: The facility policy entitled, Infection Control-Individual Immunizations, with a review date of 9/20/2023, documents, in part: Prophylactic immunizations will be offered to individuals to promote the absence of Health Care Acquired Infections . Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated and administer immunizations as ordered. Individual will be offered immunizations based upon the Center for Disease Control (CDC) recommendations and guidelines and as prescribed by their PCP. Other prophylactic treatments or immunizations will be offered to individuals per medical director…

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, review of facility food temperature logs, and facility policy review, the facility failed to ensure potentially hazardous foods (PHF) such as meat, eggs and dairy were tested for safe food temperatures prior to distribution to the residents. Specifically, hot, and cold food temperatures were not taken on 69 meals during a 90-day period. This deficient practice had the potential to affect the health of 80 of 83 residents at the facility. Findings include: Review of food temperature logs provided by the facility dated 11/12/23 through 02/19/24 revealed food temperatures had not been taken for 69 meals, primarily the dinner meal. The food temperatures had not been taken at breakfast, lunch, or dinner on nine days during that period. During an interview on 02/20/24 at 11:00 AM, the Dietary Manager (DM) stated the facility kitchen cooks breakfast; however, the lunch and dinner meals were cooked offsite and transported to the facility for distribution. The DM stated the food was placed in metal containers, put into heated boxes, and transported to the facility kitchen…

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, record review and review of the facility's incident investigation report, the facility failed to protect one of 16 sampled residents' (Resident (R) 1) right to be free from neglect when the facility failed to provide timely and appropriate toileting services. Specifically, R1 was told to urinate in her brief and was left on the bedpan for one hour which resulted in R1 being neglected. Findings include: Review of R1's undated admission Record, located in the resident's Electronic Medical Record (EMR) under the Profile tab revealed R1 was admitted on [DATE] and discharged on 11/23/23. admission diagnoses included muscle weakness, Parkinson's' disease, and osteoarthritis. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/23 indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R1 was cognitively intact. R1 was dependent on staff for bed mobility and toileting and had no rejection of care behavior…

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. This has the potential to affect all 86 residents. Surveyor observed dishwasher temperature logs not meeting manufacture requirement for sanitation. The facility did not have a practice to monitor and report findings of the dishwasher temperature logs. Surveyor observed the kitchen sink, dishwashing sink, and floors to be not cleaned properly; in addition to cobwebs with dead bugs and peeling paint, therefore causing an unsanitary environment. Surveyor observed staff without hairnets and hairnets not worn properly. This is evidenced by: Example 1 The Wisconsin Food Code 2022 documents at section 4-501.110 Mechanical Ware washing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type ware washers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74°C (165°F); (2) For a stationary rack, dual temperature…

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 interview, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Residents (R2) of 11 residents reviewed. R2 reported an allegation of abuse on 9/21/23 and 9/22/23. The facility did not thoroughly investigate the allegations reported to rule out abuse. Findings include: The facility policy titled Abuse, Neglect, Misappropriation of resident Property last reviewed on 11/8/23 included the following: .It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's Quality Assurance Program Improvement (QAPI) incident report and investigation process. The investigation is the process used to try to determine what happened. The designed facility personnel will begin investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration.The investigation will include who was involved, resident statements, resident roommate…

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 adequate supervision and safety to prevent accidents from occurring for 1 of 4 residents reviewed (R7) for 2 assist with full body lifts and 1 of 3 (R4) reviewed for wandering. R7 transfer status is care planned as two-assist with full body lift. R7 reported to surveyor that when she is transferred it is completed by Family Member J and a Certified Nursing Assistant (CNA). R4 entered R6's room while she was awake in bed and was touching her legs below the knee and shin area. R6 stated R4 would not leave her room and he made her feel creepy. R4 has a history of wandering and was wandering repeatedly prior to this incident. R4's care plan does not reflect wandering and interventions. This is evidenced by the facility policy Safe Individual Handling Program, with a review date of 6/13/23, indicates, in part: Policy: The organization will adopt the Safe Individual Handling Program as outlined below. Procedure: .B. Care Plan. 1.…

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

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 78 of 80 residents who resided in the facility (two residents received nutrition exclusively via tube feeding). Staff did not test Quaternary sanitizing solution per manufacturer's instructions. The facility did not ensure food-contact and non-food contact equipment was clean and dry for storage or use. The facility did not have a practice to monitor and document dishwashing wash and rinse cycle temperatures Findings include: Dietary Manager (DM)-J stated the facility followed the Wisconsin Food Code 2022. 1. Sanitizing Solution A package insert for Quaternary test strips used by the facility indicated the sanitizing solution should be between 65 and 75 degrees Fahrenheit (F) at the time of testing. Eco Lab instructions: For sanitization of equipment in food processing plants, restaurants, remove gross food particles and excess soil by a pre-flush or pre-scrape, wash with a good detergent or compatible…

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 4 Residents (R26, R57, R58 and R67) of 5 residents reviewed for immunizations were offered a pneumococcal vaccine. R26's medical record did not contain documentation that R26 was offered or declined a pneumococcal vaccination. R57's medical record did not contain documentation that R57 was offered or declined the Prevnar 20 vaccine. R58's medical record did not contain documentation that R58 was offered or declined a pneumococcal vaccination. R67's medical record did not contain documentation that R67 was offered or declined the Prevnar 20 vaccine. Findings include: The facility's Individual Immunizations policy, dated 7/22/22, contained the following information: 1a. Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered. b. Individual will be offered immunizations based upon the Centers for Disease Control and Prevention…

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 4 residents (R) (R7, R26, R58 and R67) of 5 residents reviewed for immunizations were provided education regarding the risks and benefits of COVID-19 immunization and either received or did not receive the vaccine due to medical contraindications or refusal. R7 did not receive a COVID-19 vaccine. R7's medical record did not indicate the facility provided education regarding the risks and benefits of the vaccine, or that R7 was not immunized due to medical contraindications or refusal. R26 did not receive a COVID-19 vaccine. R26's medical record did not indicate the facility provided education regarding the risks and benefits of the vaccine, or that R26 was not immunized due to medical contraindications or refusal. R58 did not receive a COVID-19 vaccine. R58's medical record did not indicate the facility provided education regarding the risks and benefits of the vaccine, or that R58 was not immunized due to medical contraindications or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interview, and record review, the facility did not thoroughly investigate and resolve a grievance for 1 Resident (R) (R180) of 21 sampled residents. On 6/17/23, R180 reported care concerns to staff. Staff did not follow the facility's grievance process. R180's grievance was not thoroughly investigated or resolved. Findings include: An undated Receipt of Grievance form was provided to Surveyor as the facility's policy and contained the following information: This guide will be used to take notes through-out the investigation of a grievance. It will become the source of information used to complete a report for the Quality Assurance Committee .It was generated for the sole purpose of improving the quality of services provided to our residents, patients, and clients. The form contained sections that included: Describe concern using factual terms; Investigation Findings; Resolution Description; and Resident/Representative Update Given. On 6/26/23, Surveyor reviewed R180's medical record.…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure a resident suspected of having a mental illness and/or intellectual/developmental disability was screened through the Pre-admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required for 2 Residents (R) (R26 and R71) of 21 sampled residents. The facility did not complete a PASRR Level II Screen for R26. The facility did not complete a PASRR Level II Screen for R71. Findings include: The State of Wisconsin Department of Health Services form F-22191 titled Preadmission Screen and Resident Review (PASRR) Level I Screen, dated 7/2017, contains the following information: Under these sections, 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…

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 1 Resident (R) (R26) of 4 residents reviewed for activities of daily living (ADLs) was provided AM and PM cares. R26 was not provided AM and PM cares daily which caused discomfort to R26's groin and buttocks. Findings include: In accordance with standard of care for personal hygiene of a dependent resident. [NAME], S., Fuzy, J., & [NAME], S. (2018). Heartman's Nursing Assistant Care long-term care and home care includes: CNA (Certified Nursing Assistant) may provide help with personal care and assist residents daily with these tasks. Personal care provides an opportunity for the CNA to observe a resident's skin . On 6/27/23, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with diagnoses to include history of urinary tract infection (UTI), pressure ulcer of sacral region stage 2, moisture-associated skin damage (MASD) to bilateral buttocks, urinary retention with a chronic…

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 care and treatment was provided in accordance with professional standards of practice for 1 Resident (R) (R26) of 4 sampled residents. R26 was admitted to the facility with skin damage and was not provided treatment according to physician orders. Findings include: From 6/26/23 through 6/29/23, Surveyor reviewed R26's medical record. R26 had diagnoses to include history of urinary tract infection (UTI) (last infection 5/9/23), pressure ulcer of sacral region stage 2, moisture-associated skin damage (MASD) to bilateral buttocks, urinary retention with a chronic indwelling catheter, and diabetes. R26's Minimum Data Set (MDS) assessment, dated 5/8/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R26 did not have cognitive impairment. The MDS also indicated R26 had no unhealed pressure injuries. R26 was admitted to the facility on [DATE], discharged to the hospital 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, staff and resident interview, and record review, the facility did not ensure the provision of care and treatment to prevent the development or worsening of pressure injuries for 1 Resident (R) (R35) of 7 sampled residents. R35's had a facility-acquired unstageable pressure injury on the right heel. R35 was observed in bed on multiple occasions with both heels in direct contact with the mattress. Findings include: The facility's Pressure Injury Prevention and Managing Skin Integrity policy, dated 6/24/22, contained the following information: 2. Identify Interventions and Care Plan, a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown . R35 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease (ESRD) and muscle weakness. R35's Minimum Data Set (MDS) assessment, dated 4/14/23, contained 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 3. On 6/28/23, Surveyor reviewed R47's medical record. R47 was admitted to the facility on [DATE] with diagnoses to include history of chronic urinary tract infection, urinary incontinence and indwelling catheter for wound healing. R47's most recent UTI was in May of 2023. On 6/28/23 at 9:15 AM, Surveyor observed CNA-M and CNA-T perform catheter care for R47. Prior to emptying R47's drainage bag, CNA-M placed the drainage bag on the floor without a protective barrier and did not use an alcohol wipe to disinfect the drainage spout before or after emptying the urine into a graduated cylinder. CNA-M then placed the drainage bag in a basin. CNA-M disposed of the urine in the sink and rinsed the cylinder. On 6/28/23, Surveyor interviewed CNA-T who verified R47's drainage bag was placed on the floor without a protective barrier. CNA-T stated the drainage bag contained a broken hook and CNA-T was unable to hook the bag on R47's bed. On 6/28/23 at 11:39 AM, Surveyor interviewed NM-C who verified drainage bags should 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R1) of 1 sampled resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. R1's enteral feed bag was not changed after 24 hours as ordered. In addition, the enteral nutrition (EN) formula was labeled Jevity after R1's tube feeding (TF) order was changed to Glucerna. Findings include: The American Society for Parenteral and Enteral Nutrition, Enteral Nutrition Practice Recommendations (Volume 41, Issue 1, January 2017, 15-103) indicates a label should be affixed to all enteral nutrition delivery systems and contains the following information: Include all the critical elements of the EN order on the EN label: patient identifiers, formula type, enteral delivery site (route and access), administration method and type, and volume and frequency of water flushes. Standardize the labels for all EN formula containers, bags, or syringes to 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.