Amethyst Health Of Wausau

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure residents received care and treatment based on professional standards of practice related to assessment and monitoring of pressure injuries for 2 of 5 residents (R), R41 and R21, reviewed for pressure injuries. R41's hospital discharge summary noted a pressure injury to right heel that was being treated at outpatient wound care clinic twice weekly. R41's pressure injury was not comprehensively assessed by the facility until 9/3/25. R41's interventions to offload heels when in bed were not implemented and R41 missed wound care appointment on 9/2/25. R21's care plan show shows no updates on new pressure injury versus abscess on left ischium as noted on wound assessment. No staging of area is documented in R21's medical record. No new interventions are in place in care plan. This is evidenced by: Example 1 The National Pressure Injury Advisory Panel (NPIAP) and the Wound, Ostomy and Continence Nurses Society (WOCN) emphasizes patient assessment, the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure residents (R) with indwelling Foley catheters received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) from the catheter for 1 of 3 residents (R) reviewed, R29.R29 did not have physician orders for the Foley catheter and was not provided appropriate catheter care to prevent transmission of infections.This is evidenced by:Facility's policy titled Enhanced Barrier Precautions dated 03/25/24, read in part. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs tarted gown and gloves use during high contact resident care activities.4. High-Contact resident care activities include:.g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy ventilator tubes.Facility's policy titled Emptying a Urinary Collection Bag read in part. Steps in the…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not follow professional standards of practice of care for a resident who received medication through a peripherally inserted central catheter (PICC) for 1 of 1 resident (R) R29, reviewed.This is evidenced by:Facility's policy titled Central Venous Catheter Care and Dressing Changes, revision date March 2022, read in part. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM (transparent semi-permeable membrane dressing) dressing.5. Assess central venous access devices with each infusion and at least daily: a. visually inspect the entire infusion system (solution, administration set and dressing).d. Palpate and inspect the skin, dressing and securement device for signs of complications .e. Ask the resident if he or she is experiencing pain, tingling or numbness. R29 was admitted to the facility on [DATE]. R29's current diagnoses include altered mental status, cognitive communication deficit, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure money in the resident's fund account were returned back to the resident and/or Resident Representative (RP) within 30 days after discharge or resident expiring for three of four Residents (R) reviewed for money due after discharge (R6, R7, R8). Findings include:1. Review of R6's undated Face Sheet, located under the Profile tab in the electronic medical record (EMR), indicated R6 was readmitted to the facility on [DATE], with diagnoses that included diabetes mellitus and multiple sclerosis.Review of R6's Nursing Notes, dated [DATE] at 7:12 AM and located under the Progress Note tab in the EMR, revealed, . Resident found to be deceased . No HR [heart rate], No respirations [sic]. Hospice updated .Review of R6's Resident Fund Statement Quarterly Statement for the Period of [DATE] thru [sic] [DATE], provided by the facility, indicated R6's balance was $0.40.Review of R6's Resident Fund Management Service indicated R6's Account Status was open 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, interview, and record review the facility failed to assess the need for a Wander Guard alarm, failed to assess if the Wander Guard alarm was a restraint, and failed to obtain a physician's order and written consent prior to the use of a Wander Guard alarm for one of one sampled resident (Resident (R) 4) reviewed for restraints out of a total sample of 10. These failures placed R4 at risk of having a physical restraint without indication for use Findings include:Review of the facility's policy titled, Elopement/Unsafe Wandering, revised 07/2025, indicated, . Alarms are not a replacement for necessary supervision, Staff are to be vigilant in responding to alarms in a timely manner . Monitoring and Managing Residents at Risk for Elopement or unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission, quarterly, and with a significant change in condition. b. If a resident is deemed at risk for elopement, complete the Elopement Risk Identification…

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 facility policy review, the facility failed to review and revise the comprehensive person-centered care plan to include refusal of pressure ulcer treatments and management for one of three residents (Resident (R) 1) reviewed for pressure ulcers out of a total sample of 10. This failure had the potential for R1 to experience adverse effects from refusing care.Findings include:Review of the facility's policy Care Plans, Comprehensive Person-Centered dated March 2022 indicated, . The comprehensive person-centered care plan . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents'…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and document review, the facility failed to administer pain medications per physician orders for one of three residents (Resident (R)1) reviewed for pain medications out of a total sample of 10 residents. This failure had the potential for R1 to have negative outcomes from receiving too much or too little pain medication. Findings include:Review of the facility's policy titled, Administering Medications, dated April 2019, indicated, . The individual administering the medication checks the label THREE (3) [sic] times to verify the right person, right medication, right dosage, right time, and the right method (route) of administration before giving the medication .Review of the National Library of Medicine's website, located at https://www.ncbi.nlm.nih.gov/books/NBK593215/, indicated, . The six rights of medication must be verified by the nurse at least three times before administering a medication to a patient. These six rights include the following: 1. Right Patient 2. Right…

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, interview, and facility policy review, the facility failed to have physician ordered medication available to be administered to two of three (Resident (R)1 and R2) residents reviewed for medication administration out of a total sample of 10 residents. This failure had the potential for R1 and R2 to experience unmet care needs.Findings include:Review of the undated facility policy Medication Orders and Receipt Record indicated, .Medications should be ordered in advance, when indicated, based on the dispensing pharmacy's required lead time.1.Review of R1's undated Face Sheet indicated R1 was readmitted to the facility on [DATE], with the diagnosis of an unstageable pressure ulcer to the sacral region.Review of R1's Care Plan located under the Care Plan tab in the EMR dated 03/05/25 indicated a Focus of The resident has actual impairment to skin integrity. Interventions were .Encourage good nutrition and hydration in order to promote healthier skin. Supplements as ordered.Review of 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 interview, observation, record review, and facility policy review, the facility failed to follow infection control practices during a dressing change for one of one resident (Resident (R)2) observed for a dressing change, and failed to follow infection control practices when a suprapubic catheter drainage bag was laying on the floor for one of two residents (Resident (R)3) reviewed for catheters out of a total sample of 10 residents. This failure had the potential for R2 and R3 to be exposed to infections.Findings include:1.Review of R2's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R2 was admitted to the facility on [DATE] with a diagnosis of gangrene not elsewhere classified. Review of R2's Physician's Orders located under the Orders tab in the EMR indicated an order dated 08/18/25 for wound care to the resident's right heel and left heel. During an interview on 08/19/25 at 9:30 AM, Licensed Practical Nurse (LPN)1 revealed R2 was admitted with stage…

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 necessary care and services were provided to promote healing and/or prevent pressure injuries (PI) from worsening/developing for 1 of 3 residents (R1) reviewed for pressure injuries. The facility did not complete an admission skin assessment of R1's sacral wound. Findings include: R1 was an [AGE] year-old-female admitted to the facility on [DATE], with diagnoses including diabetes mellitus type 2, severe obesity, anxiety, pressure ulcer of sacral region stage 2, urinary tract infection (UTI), stroke on 11/01/24. R1's Minimum Data Set (MDS) assessment, completed on 11/20/24, confirmed a score of 99/15, indicating R1 was not able to complete the assessment. Staff assessment of R1's mental status indicated severe impairment. R1's entry MDS assessment confirmed R1 was at risk for developing pressure injuries and a stage 2 pressure ulcer was present. R1's care plan included the following: -R1 has limited physical mobility and is non-weight…

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 provide the needed supervision to prevent accidents for 1 of 3 residents (R) R5, reviewed for accidents. Facility staff did not provide supervision while R5 was eating breakfast. Speech Therapy instructions and care plan indicated R5 required supervision to eat. This is evidenced by: Example 1 R5's progress notes indicated he had a coughing/choking episode while eating in his room, on 07/03/24. R5's care plan was updated on 07/03/24, to include: Aspiration Precautions: Alternate liquid and solid swallows. Sit upright (90 degrees) when eating and drinking either in bed or wheelchair. Diet: regular, regular consistency with thin liquids, finger foods as able. Adaptive equipment: inner lipped 3 compartment plate, Kennedy cup with lid, standard spoon with foam handle. Eating: Close supervision and assist with food. Do not leave alone with food in front of him. Speech therapy evaluated R5 on 07/11/24 and recommended close supervision while eating. On 07/31/24 at 8:30 AM, Surveyor observed Licensed Practical Nurse…

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 accurately assess pain to ensure pain management for 1 of 1 resident reviewed for pain (R22). R22's pain assessments were not accurate and R22's care plan was not individualized. This is evidenced by: The facility's policy titled, Pain- Clinical Protocol (March 2018) reads in part, The nursing staff will assess each individual for pain upon admission to the facility, at quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will evaluate how pain is affecting mood, activities of daily living, and the resident's quality of life, as well as how the pain may be contributing to complications such as gait disturbances, social isolation, and falls. The physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. On 02/21/24, R22's pain assessment indicated R22 experienced a sharp, stabbing pain to groin prior to recent hospitalization. On 02/26/24, R22'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.

Based on observation, record review and interview, the facility did not implement enhanced barrier precautions consistent with current infection control standards of practice for 1 resident (R) reviewed on enhanced barrier precautions (R7). This is evidenced by: Surveyor reviewed the facility policy title, Enhanced Barrier Precautions, dated 03/25/24. The policy in part states: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of Multidrug-resistant Organisms (MDROs) that employs targeted gown and gloves use during high-contact resident care activities that include: -Providing hygiene care -Changing briefs or assisting with toileting EBP should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Surveyor reviewed R7's record and noted: 07/02/24 - Kennedy terminal ulcer, stage 2, sacrum, in-house acquired, new (7/1/24), staged by hospice. On 07/30/24 at 10:21 AM, Surveyor observed a…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and invoice review, the facility failed to have a governing body, or a designated person function as a governing body to legally establish and implement policies regarding management and operation of the facility; the facility is in financial arrears for services that can directly affect resident care such as pharmaceutical services and the electronic healthcare software. This has the potential to affect all 25 residents residing in the facility. This is evidenced by: Policy Number: CP 1.1.0 A, in part: Governing Body Duties and Responsibilities: A. Policies and Procedures: The Governing Body is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The Governing Body, in conjunction with regular reporting by the Administrator, should assess on a regular basis that services are being provided .and that there is efficient use of resources. Appointment of Administrator: The Governing Body is responsible for appointing an…

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 resident (R) of 3 sampled residents' (R1) comprehensive care plans were reviewed and revised in accordance with the resident's current status. R1's care plan was not updated with current discharge information to return to community, not updated with goals, and not updated regarding intervention for evaluation of resident's motivation and ability to safely return to the community. Findings include: On 09/11/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE], original admission [DATE], with diagnoses including but not limited to ankylosing spondylitis of thoracolumbar region, unspecified fracture of T7-T8 vertebra, acute respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, morbid (severe) obesity due to excess calories, body mass index 50.0-59.9, other reduced mobility, chronic diastolic (congestive) heart failure, obstructive sleep apnea, unspecified atrial fibrillation, nutritional…

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 maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices in 2 of 3 total residents (R) reviewed (R1, R2). R1's and R2's medical record contained no documentation related to discharge planning to an assisted living facility. Example 1 On 09/11/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE], original admission [DATE], with diagnoses including but not limited to ankylosing spondylitis of thoracolumbar region, unspecified fracture of T7-T8 vertebra, acute respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, morbid (severe) obesity due to excess calories, body mass index 50.0-59.9, other reduced mobility, chronic diastolic (congestive) heart failure, obstructive sleep apnea, unspecified atrial fibrillation, nutritional anemia, thrombocytopenia, essential…

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 served under sanitary conditions. This practice had the potential to affect all 31 residents (R) residing in the facility. Food items in the refrigerator were past used by date: parmesan cheese, bacon, uncovered celery, hard boiled eggs, sour cream, chocolate milk and cottage cheese. Dietary Aide (DA) T touched ready to eat foods with contaminated gloved hands. This is evidenced by: The facility uses the Food and Drug Administration (FDA) Food Code as its standard of practice. Based on the Food and Drug Administration (FDA) Food Code, the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Based on the FDA Food Code .If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Expired Foods: On 08/06/23 at…

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, interviews and record review, the facility did not ensure the dishwashers were maintained and in safe operating condition. This has the potential to affect all 31 residents residing in the facility. The dishwasher was not operating properly. After the dishwasher's wash cycle, the water would not properly drain causing it to overflow on the floor of the dish room. This has the potential to spread on clean dishes in the dishwashing area. Findings include: Facility policy titled Equipment Malfunctions and Repairs stated .All equipment malfunctions and repairs will be reported to the director of food and nutrition services and/or maintenance department. On 08/06/2023 at 9:06 AM during initial tour of the kitchen, Surveyor observed the dishwasher running. The dishwasher is a low temperature machine. After the dishwashers completed the wash cycle, it drained into the floor plumbing at high pressure. Due to the high pressure, the plumbing was not able to drain properly, causing the water to overflow. Surveyor observed that the right side of the dish room was covered…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure each resident is treated with dignity in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for 3 of 12 sampled residents (R2, R20, R28) and one supplemental resident (R7). - R2 requested staff assistance for over 40 minutes while he sat in urine-soaked pants. - R20 was assisted through the hallway to the shower with hip, thigh and buttock exposure. The indwelling Foley catheter drainage bag was placed on the side of the wheelchair arm rest and urine collecting in the bag was visible to all who looked. - R28 was noted to have the urinary catheter drainage bag with urine exposed to passersby in the hallway. - R7 had a runny nose in which staff used the clothing protector to wipe the dripping and the same clothing protector was used for meal service. This is evidenced by: Example 1 R2 was admitted to the facility on [DATE]. R2's diagnoses include Parkinson's disease, history of stroke, above the knee…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure that 5 of 6 residents (R19, R13, R7, R20, and R10) reviewed for accidents, had adequate supervision and interventions in place to prevent accidents. - R19 was identified as a fall risk and sustained four documented falls at facility since 06/06/23. The facility did not identify a root cause for each documented fall, revise the care plan, or implement individualized resident-centered interventions to reduce risk of future falls. - R13 was identified as a fall risk and sustained 8 falls (07/01/23, 07/03/23, 07/08/23, 07/10/23, 07/20/23, 07/31/23, 08/01/23 and0 08/05/23) wherein 5 of the falls dated 07/08/23, 07/10/23, 07/20/23, 07/31/23, and 08/01/23 had no identifying causes of the falls or appropriate interventions taken to prevent another fall from occurring. R13's care plan was not followed with Dycem placed under resident while in wheelchair. R13's care plan was not updated with the new interventions after the fall on 08/05/23. - R7, R13, R20,…

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 establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection as evidenced by the cumulative failures of the following observations. - The facility did not ensure 11 residents (R) (R5, R7, R10, R11, R13, R15, R19, R20, R2, R3, R29) were given the opportunity to conduct hand hygiene prior to meal services; - Staff did not practice proper hand hygiene with meal service; - Staff held clean linens against their potentially contaminated uniform tops during transport; - Mechanical lifts were not disinfected after each use and prior to use for additional residents; and - Staff did not provide proper hand hygiene during resident cares. This is evidenced by: DQA (Division of Quality Assurance) memo number 11-025 outlines Resident Hand Hygiene. Included in the memo is the following: Resident handwashing is an integral component of all nurse aide training program curriculum. Nurse aides are trained to offer, encourage and/or assist residents to perform handwashing 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.

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 2 of 8 staff reviewed. Facility did not complete criminal background checks every four years for 2 of 8 employees reviewed. Findings include: Facility policy entitled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised date 04/21, stated in part, 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . 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…

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 timely assistance for 2 of 8 residents observed for Activities of Daily Living (R2 and R20) who are dependent on staff to receive these cares. - R2 went without assistance with ADLs, specifically toileting/incontinence care. R2 requested staff assistance for over 40 minutes, while he sat in urine-soaked pants. - R20 did not receive oral care. This is evidenced by: R2 was admitted to the facility on [DATE]. R2's diagnoses include Parkinson's disease, history of stroke, above the knee amputation, and seizures. R2's Minimum Data Set (MDS), dated [DATE], confirmed R2 scored 12/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R2 understands and is understood by others, and he is able to make his needs known. R2's power of attorney (POA) is activated to assist R2 with decision making. R2 is totally dependent on staff for transfers with a mechanical lift and requires extensive staff 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 observations, interviews and record reviews, the facility did not ensure 1 of 6 residents reviewed (R20) for pressure injuries (PI) received necessary treatment and services, consistent with professional standards of practice to prevent new injuries from developing. R20 has an extensive history of stage III pressure injuries on her sacrum and coccyx region with a large area of scar tissue that formed once the injury healed over and remains a very high risk of this area reopening. Two extended observations were conducted of R20 in which repositioning or offloading was not offered or attempted for an extended period of time. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue.…

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 reviews, the facility did not ensure 3 of 4 residents (R) reviewed (R20, R21 and R31) for restorative programming, received appropriate treatment and services to maintain or prevent further reduction in range of motion (ROM). R20, R21 and R31 had a therapy screen completed with recommendations for staff to follow through with restorative exercises. This is not being completed and was never implemented on the care plans for staff to follow. This is evidenced by: Example 1 R20 has medical diagnoses that include but are not limited to hemiplegia right dominant side, congestive heart failure, adult failure to thrive, obesity, muscle weakness, and right below the knee amputation. According to the most recent Minimum Data Set (MDS) assessment completed for R20, which was a quarterly assessment dated [DATE], R20 requires extensive assistance of staff to meet her most basic daily tasks of dressing, personal hygiene and toileting. R20 is dependent on staff for bathing 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 observations, interviews and record reviews, the facility did not ensure 2 of 4 residents reviewed with catheters (R20 and R25) received appropriate treatment and services to prevent urinary tract infections (UTIs) to the extent possible. R20 and R25 both have indwelling urinary Foley catheters of which observations were made of no catheter care and the tubing and urinary collection bags were frequently above bladder level, posing a risk for urinary backflow into the bladder and a potential UTI. This is evidenced by: According to the Centers for Disease Control and Prevention (CDC), to prevent Catheter Associated Urinary Tract Infections (CAUTI) it is strongly recommended to . 1. maintain unobstructed urine flow; 2. Keep the catheter and collecting tube free from kinking; and 3. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . Agency for Healthcare and Research Quality (AHRQ) states, under Maintenance of Urinary Catheters, . 3.1 Standard…

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 assure the accurate administrating of all drugs to meet the needs of each resident, resulting in 1 of 1 resident (R12) reviewed did not have insulin held per physician orders. The facility staff did not hold administering insulin to R12 as precsribed by the physician. This is evidenced by: The facility policy entitled Medication Holds revised April 2007, states .the nursing staff must document in the resident's medication administration record (MAR) that such medication(s) is being held. R12 was admitted on [DATE] and has an order for insulin Lantus 16 units one time a day for diabetes mellitus and to hold if accucheck is less than 120 or refuses meals. R12's care plan states the resident will have no complications related to diabetes through the review date with intervention of diabetes medication as ordered by doctor and to monitor/document for side effects and effectiveness. On 08/07/23 at 11:12 AM, Surveyor reviewed medication administration 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 observation, interview and record review, the facility failed to provide occupational therapy services to assess and direct the implementation and use of adaptive equipment at mealtime for 1 of 1 resident (R7), a supplemental sample, reviewed for use of adaptive equipment. R7 was not provided with specialized occupational therapy services to determine the need for and use of adaptive equipment with mealtime. R7 did not receive his adaptive cup for two of three meals observed. R7 received and used adaptive silverware that was not assessed, care planned for or documented within the medical record. This is evidenced by: R7 was admitted to the facility on [DATE], and has diagnoses that include cerebral infarction, dysphasia, aphasia, autistic disorder, and a history of aspiration pneumonia. R7's quarterly Minimum Data Assessment (MDS) dated [DATE] showed that R7 has severely impaired cognition and is rarely understood by others. R7's current physician's orders state: regular diet, regular pureed meat…

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.