Dove Healthcare - West Eau Claire

Inspectors wroteBased on interview and record review, the facility did not notify the Ombudsman of resident transfer to the hospital for 4 of 5 residents (R76, R51, R30, and R1) reviewed. R76 was transferred to the hospital on [DATE]. The Ombudsman was not notified of this transfer. R51 was transferred to the hospital on [DATE]. The Ombudsman was not notified of this transfer. R30 was transferred to the hospital on [DATE], 04/11/26, 04/17/26, 5/15/26, 5/22/26, and 5/29/26. The Ombudsman was not notified of these transfers. R1 was transferred to the hospital on [DATE] and 05/30/26. The Ombudsman was not notified of these transfers. This is evidenced by: Facility policy titled, Transfer and Discharge, with a revised date of 11/2025, states: .10. Emergency Transfers to Acute Care. h. Transfer notices will be provided to the Ombudsman. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident (R) had the right to refuse a medication for 1 of 4 residents (R76).-R76 gave non-verbal indications regarding placement of a Scopolamine patch, and Medication Aide (MA) H continued to place the patch on R76.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the timeliness of revisions for each resident's person-centered, comprehensive care plan for 1 of 18 residents (R) reviewed (R66).-R66 had tracheostomy removed on 11/12/25 and care plan currently includes interventions related to trach care.-R66 now takes food orally and is on a mashable texture. Care plan states all nutrition is administered via gastrostomy tube and is full liquid.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 4 residents (R) reviewed for pressure injuries (PI) (R1) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI. R1 was at risk for PI development and had 2 existing PIs. The facility failed to provide adequate wound care treatment to R1's PI on coccyx.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents with an indwelling foley catheter received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) for 2 of 4 residents (R) reviewed (R76 and R1) .R76 had an indwelling foley catheter which was not secured to prevent trauma or movement of catheter tubing. R1's foley catheter bag was leaking. Facility staff placed leaking catheter bag in bin placed on floor to collect the leaking urine. This is evidenced by: Facility policy titled, Catheter Care, with a revised date of 02/2026, states: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.10. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 3 residents (R) reviewed (R76). Facility did not ensure R76's percutaneous gastrostomy (PEG) tube was properly placed prior to administering medications. This is evidenced by:Facility policy titled, Care and Treatment of Feeding Tubes (Enteral Tubes), with a revised date of 05/05/25, states: .6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location: a. Tube placement will be verified before beginning a feeding and before administering medications. R76 was admitted to the facility on [DATE] with dysphagia following cerebral infarction. A PEG tube was in place on admission to administer enteral feeding and medication administration. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory therapy (R1). Registered Nurse (RN) P did not perform post respiratory assessments for R1 when administering nebulizer treatments.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medication error rates are not 5 percent or greater for 2 of 4 residents (R) observed (R76, R73).-Nursing staff did not measure Voltaren gel prior to administration for R73.-Nursing staff splashed and spilled medications prior to administration via gastrostomy tube for R76.-Nursing staff did not flush the correct amount of water between medications for R76.-Nursing staff administered sublingual medication via gastrostomy tube for R76.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 18 residents (R) reviewed (R66, R76).-Certified Nursing Assistant (CNA) N performed restorative tasks for R66 without wearing Personal Protective Equipment (PPE). R66 is on enhanced barrier precautions.-Medication Aide (MA) H did not change gloves and perform appropriate hand hygiene prior to and during medication administration involving R76's feeding tube.

Inspectors wroteBased on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 63 residents residing in the facility.

Inspectors wroteBased on observation, record review, and interview the facility did not prepare foods in a sanitary manner. Nutritional Service Aide (NSA) P did not allow the thermometer probe to air dry of alcohol prior to inserting into each of the nine food items intended to be served to residents for lunch. This had the potential to affect all 66 residents in the facilty. NSA N did not perform hand hygiene in between passing water pitchers to residents (R). This affected 10 of 10 residents observed receiving water pitchers (R48, R21, R20, R27, R22, R32, R45, R34, R60, and R269). NSA P prepared and served food to residents without proper hand hygiene and touched ready to eat foods with contaminated gloved hands. This affected 7 of 7 residents observed (R26, R267, R48, R22, R11, R6, and R268). This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 1 of 3 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent at risk of skin breakdown from occurring (R267). R267 was at risk for PI development. The facility failed to provide adequate and consistent repositioning as care planned.

Inspectors wroteBased on observation, record review and interview, the facility did not provide the needed supervision and care planned approaches to prevent a fall. The facility practice had the potential to affect 1 of 5 residents (R61) reviewed for falls. Certified Nursing Assistant (CNA) C did not remain at bedside after removing R61's bedside mat and body pillow placing R61 at risk for fall and injury. This is evidenced by: Surveyor requested and received the facility policy titled Fall Prevention Program dated 8/2024. The policy in part read: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. ~Each resident's risk factors and environmental hazards will be evaluated when developing the residents comprehensive plan of care. [...]

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, did not ensure only authorized personnel had access to medications for 3 of 3 random observations. -One observation was made of resident (R) medications left on top of the medication cart when the cart was unattended and out of view of staff. (R37) -Observation of prescribed Nystatin powder left unattended in R14's room during 2 observations

Inspectors wroteExample 3 On 3/19/25 at 6:42 AM, Surveyor observed R61's room door with a posting that read Enhanced Barrier Precautions. Surveyor observed CNA C don gloves and a gown to enter R61's room to prepare R61 for a shower. CNA C explained R61 is on Enhanced Barrier Precautions due to having a feeding tube. CNA C did not perform hand hygiene prior to donning the gown and gloves to care for R61. CNA C rolled R61 side to side in bed to remove bedding from under R61. CNA C expressed the bedding was wet. CNA C bagged the wet linens, removed her gloves and donned gloves to proceed with R1's preparation for his shower. CNA C did not perform hand hygiene when removing her soiled gloves before donning clean gloves. On 3/19/25 at 10:20 AM, Surveyor spoke with CNA C about the observation. CNA C expressed she should have done hand hygiene before donning PPE and with change of gloves. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident received adequate supervision and assistance to prevent falls and injury. This occurred for 1 of 5 residents (R) reviewed for falls, (R30). The facility did not report to oncoming staff, nor change R30's care plan to reflect the change in transfer status for R30. Staff utilized a walker to transfer R30, resulting in actual harm when R30 had a fall that resulted in a fractured femur and hip requiring surgery, and fractured rib. Thin liquids were observed in R17's room, who had a dietary order for honey-thickened liquids and not to leave R17 unattended with liquids.

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not wearing beard nets appropriately. This has the potential to affect 31 of the 64 residents residing in the facility (R34, R37, R8, R5, R1, R10, R20, R49, R29, R24, R25, R21, R23, R162, R38, R42, R40, R3, R48, R31, R28, R45, R43, R12, R19, R27, R16, R213, R35, R9, and R7).

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program for proper linen handling, urine disposal, hand hygiene, and sanitizing mechanical lifts to help prevent the development and transmission of communicable diseases and infections for 10 of 64 Residents (R). (R13, R317, R313, R315, R17, R23, R39, R5, R42, and R30)

Inspectors wroteBased on observation and interview, the facility did not ensure each resident is treated with dignity and receive assistance when requested in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for 1 of 16 residents (R) reviewed. (R17)

Inspectors wroteBased on observation, interviews and record review, 2 of the 8 dependent residents (R) reviewed did not receive required assistance with Activities of Daily Living (ADL) of incontinence cares and eating of a meal. (R17 and R30)

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with a history of pressure injuries (PI) and severe peripheral vascular disease received necessary treatment and services, consistent with professional standards of practice for 1 of 1 resident (R) reviewed with pressure injuries. (R316) R316 was admitted to the facility with a PI to the right lateral ankle and a deep tissue injury (DTI) of the right heel. The facility did not ensure R316's feet were protected, heels observed not being floated, and inconsistent assessments of the wounds were noted.