Alden Meadow Park HCC

Inspectors wroteBased on interview and record review the facility failed to ensure a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted and following accepted national standards this has the potential to affect the census (58). From Feb-April 2026 there were 33 staff call ins from work without giving their symptoms to the facility (i.e. sick) and/or had a symptom that could have been a respiratory virus symptom (i.e. cough/cold/headache/sore throat) and should have been tested prior to coming back to work. This is evidenced by: The Facilities Policy and Procedure entitled Staff Management and Exclusion dated 9/25, documents in part: [...]

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures for screening employees to prevent abuse, this affected 3 of 8 background checks reviewed. PT J (Physical Therapist) lived outside of Wisconsin (WI) in Illinois (IL) and did not have an IL or national background check completed. SSD K (Social Service Director) and Receptionist L did not have WI Caregiver Background check completed and as a result they did not have the Government Findings Report resulted. This is evidenced by:The Facilities Policy and Procedure entitled Abuse Prevention and Reporting dated 11/25 documents, in part: .III. Prevention the facility is committed to preventing abuse, neglect, misappropriation, and exploitation by fostering a culture of safety, respect, and accountability. Prevention efforts include careful employee screening .1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 1 abuse allegations of Residents (R7). R7 reported an abuse allegation involving CNA D (Certified Nursing Assistant). This incident was reported to NHA A (Nursing Home Administrator), DON B (Director of Nursing), and CNA F (Certified Nursing Assistant), but was not reported to the state agency. Evidenced by: Facility policy titled Abuse Prevention and Reporting Policy, undated, states, in part: . III. Prevention. Orientation and Annual Training Topics include: . Identification, prevention, and reporting of abuse under both federal and Wisconsin law. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 1 of 1 resident (R7) reviewed for abuse. On 4/6/26, the facility became aware of an allegation of abuse by a Certified Nursing Assistant (CNA) to a resident and did not conduct a thorough investigation. Evidenced by: Facility policy titled Abuse Prevention and Reporting Policy, undated, states, in part: . III. Prevention: The facility is committed to preventing abuse, neglect, misappropriation, and exploitation by fostering a culture of safety, respect, and accountability. 3. Resident and family engagement: All residents and families are informed of the facility's grievance and concern procedures. Resident and family concerns are documented, investigated, and reviewed. 4. [...]

Inspectors wroteBased on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice (Wisconsin Nurse Practice Act, N6) related to assessment and monitoring of a resident's change in condition. This had the potential to affect 1 of 3 sampled residents (R1). R1 reported to staff that an event occurred at her time away from the facility that caused an increase in pain to her leg/foot. The facility did not complete a Registered Nurse (RN) Assessment timely. Staff observed R1 to have swelling and bruising after the change in condition was noted, staff failed to continuously assess, record, and monitor R1's change in condition for new or worsening symptoms. R1's x ray results showed a questionable non-displaced fracture of the tibia metaphsis (neck portion of a long bone). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, and including injuries of unknown source, are reported immediately for 1 of 3 residents (R) reviewed for abuse (R1). R1 had an injury of unknown source on 11/7/25 and 11/9/25 that the facility was aware of and did not report the injuries of unknown source to the State Agency. This is evidenced by: The facility's policy Abuse Prevention and Reporting Policy, dated 11/25, includes: I. Purpose To ensure all residents are free from abuse, neglect. This policy establishes clear expectations for the prevention, identification, investigation, and reporting of all allegations or reasonable suspicions of mistreatment. IV. Identification and Reporting 3. Nursing staff must report bruising of unknown origin or other abnormalities. 4. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to injuries of unknown source, that all alleged violations are thoroughly investigated to rule out the potential for abuse for 1 or 3 residents reviewed (R1). R1 had an injury of unknown source on 11/7/25 and 11/9/25 that the facility was aware of and did not complete a thorough investigation of these injuries. This is evidenced by: The facility's policy Abuse Prevention and Reporting Policy, dated 11/25, includes: I. Purpose To ensure all residents are free from abuse, neglect. This policy establishes clear expectations for the prevention, identification, investigation, and reporting of all allegations or reasonable suspicions of mistreatment. IV. Identification and Reporting 3. Nursing staff must report bruising of unknown origin or other abnormalities. 4. [...]

Inspectors wroteBased 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 for 1 of 3 sampled residents (R1) for change of condition. During interviews staff indicated R1 had experienced an increase in pain, a bruise, and swelling to her lower left extremity on 11/7/25. Hospice Nurse Notes reflect R1 was experiencing pain 9 out of 10, 10 out of 10, and 7 out of 10. R1's medical record does not accurately reflect her pain. R1 reported an event happened while she was off premises at an appointment with one or two staff members. R1 reported the event with inconsistent details to facility staff and to hospice staff. Staff failed to capture R1's allegation/details of the event in her medical record. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS.) This has the potential to affect all 65 residents residing within the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for four fiscal year quarters for excessively low weekend staffing, triggered one fiscal year quarter for failure to have licensed nursing coverage 24 hours a day, and triggered for one fiscal year quarter for failure to have RN (registered nurse) hours each day Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the current copy of a resident's advance directive was reflected accurately in the resident's medical record, for 1 of 17 sampled residents (R312) reviewed for advance directives. The facility had an incorrect advanced directive order in R312's medical record. Evidenced by: The facility policy, entitled Advance Directives, dated 11/22, states, in part: . A. Policy: The Social Service Director and/or designee will assess, care plan and implement Advance Directives. B. Procedure: . 7. All advanced directive preferences will be documented in the resident's care plan and updated quarterly, annually and upon any significant changes in cognition. 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to receiving treatment and supports for daily living for 1 (R33) of 17 resident rooms observed. R33's room had both breakfast and lunch trays containing food and dirty dishes for hours after the meals had been served. This is evidenced by: The State of Operations Manual Appendix PP states in part: . Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide repositioning for dependent residents for 1 of 1 residents (R) reviewed for Activities of Daily Living (ADLs) assistance (R33). Staff did not assist R33 with repositioning in her wheelchair per her plan of care. Evidenced by: Facility policy, entitled Activities of Daily Living, dated 3/10/22, states in part: .assist resident to perform ADL's (grooming, dressing, oral hygiene, transfer, ambulation, toileting, etc.) and encourage resident to participate as much as the resident is able . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 1 residents reviewed for mobility (R33). The facility was not walking R33 in accordance with her plan of care. This is evidenced by: Facility policy titled Restorative Nursing Program, dated 3/10/22 states, in part: Policy: It is the policy of this facility that a resident is given the appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the resident's ability to adapt and adjust to living as independently and safely as possible . 1. The purpose of the Restorative Nursing Program is to: a. Restore to original status or improve level of independence after a decline in Activities of Daily Living (ADLs), and/or . d. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 Residents (R) reviewed for pain (R33). The facility failed to adequately assess R33's pain or provide non-pharmacologic interventions to treat her pain. This is evidenced by: The facility policy titled, Pain Management, dated 4/19/12 states, in part: Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 1. Residents shall be assessed for pain and his or her manner of expressing pain upon admission, re-admission, and annually . 3. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was submitted to the State Survey Agency within two hours after the allegation was made and failed to submit the results of the investigation to the State Survey Agency within five working days of the incident for 2 (Resident #1 and Resident #2) of 4 residents reviewed for resident-to-resident abuse.

Inspectors wroteBased on observation, interview, record review, and facility clinical guideline review, the facility failed to ensure staff used proper hand hygiene during wound care, which affected 1 (Resident #6) of 2 residents observed for wound care.

Inspectors wroteBased on interview and record review, the facility did not permit a resident to remain in the facility and not discharge the resident from the facility when R1 was pending Medicaid eligibility. On 8/7/24, R1 was given a Discharge Notice indicating R1 was going to be discharged on 9/7/24 to a hotel or apartment due to nonpayment. R1 was actively applying for Medicaid and a decision was pending. The facility discharged R1 despite pending Medicaid eligibility. Evidenced by: The facility's Discharge Planning policy, dated 11/17, includes, in part, the following: A. Policy: The resident's potential to discharge will be assessed with the resident/their representative initially, quarterly, annually and with significant changes. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that 1 of 16 residents reviewed for ADL care (Activities of Daily Living) received the necessary services to maintain good nutrition grooming, personal and oral hygiene. R18 voiced concern of not receiving oral care. This is evidenced by: The facility policy, entitled Morning Care, General Guideline, dated 9/20, states in part: .5. Encourage resident to perform ADL's (grooming, dressing, oral hygiene, transfer, ambulation, toileting, etc.) or to participate as much as the resident is able . R18 was admitted on [DATE] with diagnoses which include assistance with personal care, unspecified lack of coordination, cerebellar ataxia in diseases classified elsewhere (damage to the part of the brain that control muscle coordination). R18's Care Plan, initiated: 12/3/22, states, .Focus: [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services 1 resident (R32) of 1 of 2 sampled residents reviewed for G/T (gastrostomy tube) care. Facility staff did not check placement of R32's G/T by residual prior to medication administration. This is evidenced by: The facility policy entitled, Enteral Nutritional Feeding dated 9/20, states in part: .Procedure: .8. Check position of tube for proper placement .a. Check residual by placing barrel of syringe into tube and pulling back on syringe. If contents less than 100 ml (milliliters), return aspirate contents to the resident. Proceed with feeding. If content is greater than 100 ml, replace contents, turn off feeding and call MD (medical doctor)/NP (nurse practitioner) . [...]