Sauk Co Health Care Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide wound care and monitoring in accordance with professional standards of practice and its own wound policy for a resident with severe cognitive impairment and multiple comorbidities. On 12/10/25, staff observed and documented an open area on the resident’s left fifth digit, noting only that the left hand pinky had an open area reported to the supervisor. No initial comprehensive wound assessment was completed at that time, and there was no documentation of wound measurements, size, or characteristics as required by the nursing process and by wound assessment best practices. The facility’s care plan identified the resident as at risk for impaired tissue integrity and directed nurses to inspect skin and assess skin status, but the documentation for this new wound remained limited to brief notes that treatment was done per order. On 12/11/25, the physician ordered cleansing of a scab on the left pinky with soap and water and application of betadine, to be left open to air. Over the following days, progress notes repeatedly documented that wound treatment was done per order or that there was “wound care to left pinky as ordered,” without any detailed wound assessments, measurements, or descriptions of wound bed, edges, exudate, peri-wound skin, or pain. A weekly skin assessment on 12/15/25 described the skin as within normal limits with a small wound to the left pinky being treated, but again did not include a thorough wound assessment. Later on 12/15/25, staff documented that the left pinky nail appeared to be falling off with no signs or symptoms of infection, but there was no documented comprehensive assessment of this change and no physician notification recorded in the resident’s record. From 12/10/25 through 12/19/25, there is no documentation of systematic wound assessments to indicate that staff were monitoring the wound for decline or improvement. On 12/19/25, staff noted a change in the wound appearance and reported that the left pinky was cleaned as ordered and the charge nurse was notified. Later that day, documentation described a large hematoma on the lateral aspect of the left pinky, red and warm, and the POA and on-call physician were contacted, resulting in transfer to the emergency department. In the ED, the left pinky was found to be quite swollen with purplish discoloration and purulent drainage, and the resident was diagnosed with an abscess and a possible nondisplaced fracture of the distal phalanx. Subsequent evaluations, including review of radiographs and consultation, identified erosive bone loss of the fifth distal phalanx consistent with osteomyelitis, and the NP stated that bacteria likely entered through the open area. The surveyor found no incident report, no weekly wound assessment documentation, and no evidence of wound monitoring or assessment between the initial finding of the open area and the development of the hematoma and abscess, and facility leadership acknowledged that wound assessments were not completed for what they characterized as a blood blister or hematoma.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to timely report an injury of unknown origin, later identified as a closed nondisplaced fracture of a resident’s left pinky finger, to the State Survey Agency as required by policy and regulation. The facility’s written policy on Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation states that all allegations of abuse, neglect, mistreatment, injuries of unknown source, or misappropriation of property must be promptly investigated and reported to appropriate agencies in accordance with state and federal laws. The policy further specifies that serious injuries must be reported to law enforcement no later than two hours after discovery and nonserious injuries no later than 24 hours after discovery, and that injuries of unknown origin are to be treated as potential misconduct requiring immediate reporting and investigation. The resident involved had significant medical and cognitive impairments, including cerebrovascular disease, unspecified severe dementia with anxiety, and bilateral osteoarthritis of the hips. A Significant Change MDS dated 1/22/26 documented severe cognitive impairment with a BIMS score of 00, indicating the resident was unable to reliably report or explain events. On 12/19/25, nursing documentation noted a change in the appearance of the resident’s left pinky finger, including a large, red, warm hematoma on the lateral aspect of the finger. The POA and on-call physician were notified, and the resident was transferred to the emergency department for evaluation of the hematoma and possible abscess. Hospital records from that same day documented that the resident presented with hand pain and a swollen left pinky with purulent drainage, with the source of injury unclear. Radiologic imaging showed a possible nondisplaced fracture of the distal phalanx of the left little finger, and the discharge diagnosis included an abscess and a closed nondisplaced fracture. During the survey, an LPN reported that the finger had been broken about a month earlier and that she was not aware of how the fracture occurred, and the DON confirmed there was no incident report or weekly wound assessment documentation for the injury. The Nursing Home Administrator acknowledged in interview that an injury of unknown source should be reported to the state and that this resident’s fracture should have been reported and investigated to determine the cause, but this was not done within the required timeframe, resulting in the cited deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to thoroughly investigate an injury of unknown origin and to respond in accordance with its abuse/neglect and injury-of-unknown-source policies. The facility’s written policy, dated 12/2025, requires that all allegations of abuse, neglect, mistreatment, injuries of unknown source, and resident rights violations be promptly and thoroughly investigated, with immediate measures taken to ensure resident safety, timely reporting to the administrator and appropriate agencies, and completion of a Caregiver Misconduct Incident Report within five working days. The policy also defines injuries of unknown origin as those where the source is not observed or cannot be explained by the resident and is suspicious due to extent, location, or pattern of injuries, and outlines specific investigative steps such as interviewing staff and residents and reviewing prior shifts. The resident involved was admitted with multiple significant medical conditions, including cerebrovascular disease, severe unspecified dementia with a BIMS score of 00, anxiety, and bilateral hip osteoarthritis. Progress notes show that on 12/19/25, staff documented a change in the resident’s left pinky finger, initially noting skin problems and later describing a large, red, warm hematoma on the lateral aspect of the finger. The resident’s POA and on-call physician were notified, and the resident was transferred to the emergency department that evening. Hospital records from that visit document that the resident presented with hand pain and a swollen left pinky with pus drainage, with the history noting it was unclear whether there had been an associated injury. Diagnostic imaging at the hospital identified a possible closed nondisplaced fracture of the distal phalanx of the left little finger, along with an abscess. During a subsequent surveyor interview, an LPN reported that the finger had been broken about a month earlier, that osteomyelitis had been found, and that the resident’s left hand was contracted, requiring staff to pull the fingers up to apply palm protectors, but the LPN was not aware how the fracture occurred. When the surveyor requested an incident report and weekly wound assessments related to the injury, the DON stated there was no incident report and no weekly wound assessment documentation. In a separate interview, the administrator acknowledged that an injury of unknown source should be reported to the state and that the resident’s finger fracture should have been investigated to determine its cause, confirming that the required investigation and reporting processes were not carried out.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by policy and regulation. The deficiency involved two residents with severe cognitive impairment, both of whom were involved in incidents where a staff member allegedly used threatening and demeaning language. The facility became aware of these allegations but did not report them to the State Agency within the required timeframe. One resident with vascular dementia reported to a surveyor that staff yelled at her often, which made her feel not good. A Certified Nursing Assistant (CNA) observed another CNA being reckless with residents and overheard the staff member threaten to "beat your butt" to a resident. The CNA reported the incident to a nurse and the Director of Nursing (DON), expressing concern for her own safety and requesting police involvement. The DON sent the alleged perpetrator home and notified the Nursing Home Administrator (NHA), but the incident was not reported to the State Agency. Another resident with Alzheimer's Disease and metabolic encephalopathy was also involved in the incident. The NHA and DON both acknowledged that the incident constituted an allegation of abuse and that it should have been reported to the State Agency within two hours. However, the NHA decided not to report the incident after conducting an internal investigation and determining that witness statements varied and one CNA would not provide a statement. Despite facility policy requiring immediate reporting and investigation, the required notification to the State Agency did not occur.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an allegation of verbal abuse involving two residents with severe cognitive impairment. The incident was reported to the Director of Nursing (DON) by a CNA who overheard another CNA making threatening statements to residents, including threats to 'slap' and 'beat' them. The DON notified the Nursing Home Administrator (NHA), who arrived at the facility, spoke with staff, and requested written statements. However, the investigation did not include interviews with the residents involved, despite their cognitive impairments, and relied primarily on staff statements and a skin check conducted the following morning. The facility's policy requires immediate intervention to ensure resident safety, including removing the alleged perpetrator from the facility and suspending them from duties during the investigation. Although the accused CNA was initially sent home, records show that the CNA continued to work at the facility on subsequent days while the investigation was ongoing. This failure to remove the accused staff member from resident care duties meant that resident safety was not ensured during the investigation period. Additionally, the facility did not report the abuse allegation to the state agency within the required two-hour timeframe, as acknowledged by both the NHA and DON during interviews. The investigation was incomplete, lacking resident interviews and timely reporting, and did not fully adhere to the facility's own abuse investigation and reporting policies. The documentation provided by the facility included staff education and signature sheets, but did not demonstrate a comprehensive or timely response to the abuse allegation.

Penalty

Inspection fine: $123,000

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care to prevent pressure ulcers for a resident identified as R19, who was at risk due to decreased mobility, bilateral above-knee amputation, and radiation therapy. R19 developed a facility-acquired stage 3 pressure injury (PI) that was not properly identified or staged by the facility. Instead, the facility considered it a chronic wound caused by friction and shearing from the use of a slide board transfer. Despite recognizing these risk factors, the facility continued to use the slide board and did not document any risk versus benefits discussion with R19 regarding its continued use. R19's medical history included prostate cancer, heart disease, venous insufficiency, and peripheral vascular disease, among others. The resident's care plan included the use of a Roho cushion and repositioning every two hours to prevent skin breakdown. However, there were delays in obtaining the Roho cushion, and R19 was observed using a rolled washcloth under his hip, which contributed to the PI. The facility did not provide alternative transfer methods to the slide board or adequately educate R19 on the risks associated with its use, leading to the deterioration and infection of the PI, which eventually required an EpiFix graft. The facility's failure to appropriately stage the PI and provide alternative transfer methods resulted in immediate jeopardy. The wound physician had identified the wound as a stage 3 pressure injury, but the facility did not classify it as such. The facility's inaction and lack of documentation regarding risk versus benefits discussions contributed to the development of two facility-acquired pressure injuries for R19, with the left ischial tuberosity deteriorating and becoming infected.

Removal Plan

• R19 was educated on Risks vs Benefits regarding use of the slide board and placing barrier on top of pressure relieving device which decreases effectiveness.
• Resident was consistently refusing interventions including, but not limited to, nutritional supplements, attending scheduled appointments regularly, participating in therapy and following recommendations of using Hoyer Lift instead of the slide board. This was also included in his Risks vs Benefits education.
• Nursing staff was educated regarding: Prevention of Pressure Injury, including: A. Pressure Points, Shearing, Friction and Proper Positioning. B. What to look for regarding what interventions are working and what are not.

Penalty

Inspection fine: $123,000

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional practices, leading to the presence of expired medications in the facility. During the survey, it was observed that several medications, including Loperamide, Escitalopram, Naproxen, insulin pens, and Promethazine suppositories, were expired and still in circulation. The surveyor noted that medication carts and storage rooms contained these expired drugs, which were not removed or returned to the pharmacy as required by the facility's policy. Interviews with nursing staff revealed a lack of awareness regarding the expiration dates of medications, as some medication cards did not display expiration dates, and staff were unsure of how to determine them. The staff had to contact the pharmacy to confirm expiration dates, indicating a gap in the facility's medication management system. The Director of Nursing was informed of the expired medications, acknowledging that they should not have been in circulation, and indicated that education for the nursing staff was underway.

Penalty

Inspection fine: $123,000

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its policies and procedures to prohibit and prevent abuse, neglect, and theft, as evidenced by the lack of a complete background check for an LPN hired by the facility. The facility's policy on Prevention/Reduction of Resident Abuse, Neglect, Exploitation, or Misappropriation of Property requires a criminal background check for all prospective employees. Additionally, the Care Giver Background Investigations policy mandates obtaining out-of-state conviction records if a caregiver has lived outside the state in the last three years. However, the facility did not conduct an out-of-state criminal background check for an LPN who had resided outside of Wisconsin within the last three years. The deficiency was identified during a surveyor's review of the LPN's background check information, which revealed the absence of an out-of-state criminal background check. The Nursing Home Administrator acknowledged that the facility did not complete the required out-of-state background check for the LPN, despite the facility's policies clearly stating the necessity of such checks. This oversight indicates a failure to adhere to established procedures designed to ensure the safety and well-being of residents by thoroughly vetting potential employees.

Penalty

Inspection fine: $123,000

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate catheter care and hand hygiene for a resident, identified as R25, who was at risk for urinary tract infections. R25, who is cognitively intact and has a history of urinary retention and obstructive uropathy, was observed receiving catheter care from CNA H. During this process, CNA H did not change gloves or perform hand hygiene after completing catheter care and before handling the resident's gait belt and clothing. This action was contrary to the facility's hand hygiene policy, which requires hand washing or the use of alcohol-based hand rubs before and after direct contact with residents and after handling waste materials. The deficiency was further highlighted during an interview with CNA H, who acknowledged the failure to perform hand hygiene and glove changes as required. The Director of Nursing (DON B) also confirmed that hand hygiene and glove changes should have been performed between catheter care and assisting the resident with their clothing and mobility. This oversight in following proper infection control procedures could potentially contribute to the spread of infections, particularly given the resident's susceptibility due to their medical conditions.

Penalty

Inspection fine: $123,000

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have a medication error rate of 6.9%, exceeding the acceptable threshold of 5%. This was determined through observation, interview, and record review during a medication pass task involving seven residents. Two errors were identified among 29 opportunities, affecting two residents. The errors involved the failure to administer medications at the ordered times, which is a violation of the facility's medication administration policy. The first error involved a resident with a history of hemiplegia and hypertensive heart disease, who did not receive her prescribed senna at the scheduled time. The Licensed Practical Nurse (LPN) responsible for administering the medication mistakenly believed she had given it and signed it off as administered. Upon being informed of the oversight, the LPN acknowledged the error and suggested administering the medication at a later time, which deviated from the prescribed schedule. The second error involved another resident with hypertensive heart and kidney disease, who received aspirin at the wrong time. The aspirin was ordered to be given at bedtime, but the LPN administered it earlier in the day. The LPN admitted to noticing the error but proceeded with the administration regardless. The Director of Nursing confirmed that both instances were medication errors, as the medications were not administered at the ordered times.

Penalty

Inspection fine: $11,723

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care and services consistent with professional standards of practice for a resident who experienced a significant change in condition. The resident, who had a history of dementia, chronic kidney disease, and other health issues, presented with symptoms including decreased appetite, abdominal pain, fatigue, nausea, and vomiting. Despite these symptoms, the facility did not complete a gastrointestinal/abdominal assessment or notify the resident's physician about the abdominal pain. This oversight led to the resident becoming lethargic and eventually being transferred to the hospital, where a perforated colon and pneumoperitoneum were diagnosed. The nursing staff and CNAs observed changes in the resident's condition, such as a distended abdomen, decreased appetite, and lethargy, but failed to take appropriate action. Interviews with staff revealed that the resident's symptoms were reported to nurses, but there was no evidence of a comprehensive nursing assessment being completed. The facility's policy required immediate notification of the physician and documentation of any acute change of condition, but these steps were not followed. The lack of timely assessment and communication with the physician resulted in a delay in addressing the resident's deteriorating condition. The resident was eventually transferred to the hospital with severe symptoms, including hypotension and altered mental status, and was found to have a small bowel obstruction and bowel perforation. The facility's failure to recognize and respond to the resident's change of condition created a situation of immediate jeopardy, highlighting a significant deficiency in the care provided.

Removal Plan

• DON and ADON did a complete facility wide sweep to determine if any residents had a COC.
• Any residents identified with a COC had an immediate nursing assessment completed and MD/POA updated.
• DON and ADON reviewed the 24-hour report to confirm accuracy and to identify any other residents with a potential COC.
• DON educated nursing staff and reiterated the importance of completing accurate nursing assessments and documentation in a timely manner.
• Education on what to include in a thorough GI/digestive assessment and how to interpret the results.
• If assessment is abnormal, following with COC protocol including MD/POA notification.
• All staff received immediate education prior to their next working shift on Change of Condition, Nursing Documentation/Assessment, MD/POA Notification, 24-hour report should be brought to morning clinical meeting and afternoon stand down.
• 24-hour reports should include, but are not limited to: resident COC, follow up assessments, negative behaviors, pressure injuries, falls, resp/GI symptoms admissions, discharges, room changes, appointments, MD rounds, new orders, care plan changes, medication changes, therapy updates, refusals, change in functional and cognitive status.
• Audits will be completed on all the above items. Findings will be presented at least quarterly at QAPI.
• Nurses and CNAs were given Skills Assessment sheets to determine what area of focus is needed to perform job duties effectively.
• DON and/or ADON will review Assessment sheets, educate.

Penalty

Inspection fine: $11,723

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and safety measures for a resident, leading to a fall and subsequent injuries. On September 2, 2024, a resident was in the shower room when a CNA attempted to remove an incontinent product while the resident was seated in a shower chair. This action caused the resident to begin to fall, and the CNAs assisted the resident to the floor. However, the CNAs moved the resident without a nurse's assessment, which is against the facility's fall policy. As a result, the resident sustained a fracture to the right tibia and fibula. Following the initial incident, the resident was not properly assessed for further injuries, leading to a delay in identifying a left femur fracture. The fracture was discovered later when the resident was sent to the hospital due to an open fracture of the left femur. The facility's failure to follow proper procedures for fall assessment and supervision resulted in significant harm to the resident, including multiple fractures and the need for hospitalization. The facility's policy on fall prevention and accident procedures was not adhered to, as evidenced by the CNAs' actions and the lack of immediate nursing assessment. The incident highlighted deficiencies in staff training and adherence to safety protocols, which contributed to the resident's injuries. The facility was found to be in immediate jeopardy due to these failures, which posed a serious risk to the resident's health and safety.

Removal Plan

• DON and ADON did a complete facility wide audit on transfer status of all residents to confirm accuracy on the care card.
• Resident care plans were reviewed for transfer status and ensured accuracy.
• All staff received immediate education on transfers and falls.
• Reviewed transfer policy and procedure and will present to all staff.
• Always follow care card on how to transfer resident.
• Always use a gait belt when transferring resident.
• Always use 2 people for Hoyer transfer.
• Do not bump arms/legs during transfer.
• Do not attempt to remove garments resident is sitting on or pull on the garments a resident is sitting on.
• Take time to ensure resident is ready for transfer into shower chair, all articles of clothing are off. If not, use safe transfer method to stand up or lay resident down.
• Always report to nurse if resident is not tolerating current transfer method.
• Reviewed facility fall policy and procedure and will present to all staff.
• If resident falls, activate emergency cord and if no response, call out.
• DO NOT move resident until an RN assesses for injury.
• RN to complete fall assessment including neurological and body assessment with vitals.
• If injury, update MD and call 911 to send to hospital for evaluation if ordered.
• Update: POA, DON/ADON, Administrator.
• Reviewed COC policy and procedure and will discuss with all nursing staff on recognition of COC and MD Notification.
• CNA's report any and all skin changes to your nurse immediately.
• Nurse assess skin and document with measurements.
• Update DON and Wound Nurse.
• Update MD and POA.
• Audits will be completed on all of the above items. Findings will be presented at least quarterly at QAPI.
• The facility will begin auditing resident transfers.
• All falls will be audited for the following: Root Cause identification MD Notification; POA/Family Notification, if applicable, Care Plan updated, RN Assessment done.

Penalty

Inspection fine: $11,723

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor a resident's drug regimen, leading to adverse consequences. The resident, who had a diagnosis of Atrial Fibrillation and was on Coumadin, was prescribed Bactrim, an antibiotic known to potentiate the effects of Coumadin. The facility did not complete the necessary monitoring for symptoms of drug interactions, which resulted in the resident being sent to the hospital with a supratherapeutic INR of 4.5, significantly higher than the therapeutic range of 2-3. The facility's policy on Warfarin monitoring requires that all residents receiving Warfarin therapy be monitored for efficacy through observation and PT/INR testing. However, the facility did not follow this policy when the resident was placed on Bactrim. There was no indication that the facility informed the physician or the anticoagulation clinic about the resident's Coumadin therapy when Bactrim was prescribed. Consequently, the resident's INR was not monitored during the course of Bactrim treatment, leading to a critically high INR level. Interviews with the Director of Nursing revealed that the facility should have contacted the anticoagulation clinic and checked the INR within 1-3 days after starting the antibiotic. However, this process was not followed, resulting in the resident's increased risk for bleeding due to the high INR. The lack of communication and monitoring contributed to the deficiency in ensuring the resident's drug regimen was free from unnecessary drugs and adverse consequences.

Penalty

Inspection fine: $26,254

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care to prevent and treat pressure injuries for resident R12, leading to the development of an infected stage 4 pressure injury. Despite R12's complex medical history, including nonverbal vascular dementia, severe Peripheral Arterial Disease, and other conditions, the facility did not consistently follow professional standards of practice in preventing and treating pressure injuries. Observations revealed instances where R12 was not repositioned regularly, had poor hand hygiene during wound care, and did not have his heels offloaded as ordered, all contributing to the development and worsening of the pressure injury. Furthermore, staff were not adequately addressing R12's pain management needs during wound care, as evidenced by R12 exhibiting signs of pain during the procedures. The facility also lacked proper documentation and communication with R12's Medical Doctor regarding changes in the wound status, such as the presence of slough and foul odor. Inconsistencies in wound assessments and inadequate reporting of important details, like the characteristics of the wound bed and drainage, further highlight the deficiencies in care provided to R12. The facility's failure to adhere to its own policies and procedures related to pressure injury prevention and treatment, as well as the lack of timely and appropriate interventions, resulted in the escalation of R12's pressure injury to an infected stage 4 ulcer. The deficiencies in care observed by surveyors, including inadequate pain management, poor wound care practices, lack of repositioning, and insufficient communication with the medical team, all contributed to the immediate jeopardy situation identified for resident R12.

Penalty

Inspection fine: $26,254

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that four sampled residents received treatment and care in accordance with professional standards of practice for foot care. Specifically, the facility failed to provide daily diabetic foot checks as required by current standards of practice. The facility's policy on foot care did not reflect these standards, and there were no physician orders or comprehensive care plans indicating the need for daily diabetic foot checks for the residents involved. Interviews with nursing staff confirmed that foot checks were performed weekly or bi-monthly, rather than daily as required. Resident 1, who has Type 2 Diabetes Mellitus with diabetic neuropathy, did not have daily foot checks documented in their Medication/Treatment Administration Record (MAR/TAR) or physician orders. Similarly, Resident 12, with multiple diagnoses including severe Peripheral Arterial Disease and Diabetes Mellitus Type 2, also lacked daily foot checks in their care plan and physician orders. Resident 13, with Type 2 Diabetes Mellitus and a history of pressure ulcers, and Resident 35, also with Type 2 Diabetes Mellitus, were found to have similar deficiencies in their care plans and physician orders. Interviews with the Director of Nursing (DON) and Registered Nurses (RNs) revealed a lack of awareness and adherence to the current standards of practice for daily diabetic foot checks. The DON indicated that Certified Nursing Assistants (CNAs) regularly checked feet, but nurses only performed checks weekly or bi-monthly. This discrepancy between the facility's practices and the required standards of care led to the identified deficiencies in foot care for the diabetic residents.

Penalty

Inspection fine: $26,254

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve food at an appetizing temperature, affecting four residents. Observations and interviews revealed that hot food was not always served hot and cold food was not served cold. Specifically, a test tray with French toast sticks, bacon, yogurt, and crushed strawberries showed that the French toast sticks were at 102.3 F and hard, while the crushed strawberries were at 60 F, both failing to meet the facility's policy requirements. Residents R3, R32, R36, and R20 all reported that their breakfast items, such as French toast sticks and crushed strawberries, were not served at the appropriate temperatures. The Dietary Manager acknowledged the issue, stating that hot foods should be served hot and cold foods should be served cold. The manager also mentioned plans to improve meal temperatures by serving meals in kitchenette areas. Despite these plans, the deficiency was evident as residents consistently reported receiving meals at incorrect temperatures, and the test tray confirmed these concerns. The facility's failure to adhere to its food temperature policy resulted in the deficiency noted by the surveyors.