Mercy Manor Transition Center

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident received, and the facility provided, care and services consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 4 residents (R1) reviewed for change of condition. On [DATE], R1 presented with a change of condition including weakness, abnormal lung sounds, a fever of 102.6, cough, influenza positive, and shortness of breath. As the day progressed, R1 continued to deteriorate with increased symptoms of difficulty breathing and weakness. The facility failed to complete a comprehensive nursing assessment by a registered nurse and failed to consult with a physician even as R1's condition continued to deteriorate. R1 expired at the facility on [DATE] at 11:58 PM. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency timely and to local law enforcement for 1 of 3 residents reviewed for abuse (R2). R2 voiced an allegation of sexual abuse by CNA N (Certified Nursing Assistant). The facility failed to report the allegation to the State Agency within 2 hours of the allegation being voiced. The facility failed to report the allegation of sexual abuse to the local law enforcement.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 8 residents who reside in the facility. Surveyor observed a box of spoiled lemons in the refrigerator. Surveyor observed undated food in the dry storage area, in freezer (1) and the smaller freezer. Surveyor observed a staff member's personal water bottle in the food prep area. Surveyor observed chunks of rubber missing from 4-5 spatulas. Surveyor observed the flip tops of 2 garbage cans open and one large garbage can without a lid. Facility staff was observed testing the temperature of the water in the sanitizing sink. The temperature was out of the manufacture's recommendations. Evidenced by: The facility policy, entitled Food & Nutrition Services Policy NO. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 8 residents (R8) reviewed for Activities of Daily Living (ADL) received the necessary services to maintain personal hygiene. R8 voiced concern he did not receive showers as scheduled. Evidenced by: The facility policy, entitled Care Services Provided, last reviewed on 1/2024, states, in part: . General nursing care that will be provided, at a minimum, in addition to the individualized interdisciplinary plan of care is: . Procedure: 5. Hygiene care includes offering bathing (in a shower, trimming of nails weekly, shampooing of hair, application of personal products such as deodorants, etc.) Restorative nursing and psychosocial care will bill be provided continuously. These measures will include, at a minimum, the following: 4. ADL maintenance and retraining: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risk of entrapment, advise of the risk and/or benefits and obtain consent prior to use of bed rail with air mattress for 1 of 2 residents in the facility (R4). The facility failed to assess R4's risk of entrapment, advise of the risk and/or benefits and did not obtain consent prior to installing bed rails. Evidenced by: The facility's Use of Side Rails, last revision date 01/24, includes, in part, the following: It is the policy of (Name of the Facility), that the use of side rails be compliant and consistent with all Federal and State regulatory requirements. It is recognized that, although the reasons for use may differ related to resident-specific needs, side rails are, by definition, a form of restraint and subject to all of the regulatory requirements that currently govern the use of restraints. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 11 residents. Surveyor observed kitchen staff miss handwashing opportunities while preparing residents' meals. Surveyor observed food in circulation that was opened and undated. Surveyor observed a hair net not properly worn. Surveyor observed a dented can in circulation. Surveyor observed the oven was not cleaned properly. Surveyor observed no temperature logs for the refrigerator/freezer unit in the facility's dining room. This is evidenced by: Hand Washing The facility policy entitled, Hand Hygiene, revised on 4/25/23, states in part: Policy Statement . [...]

Inspectors wroteBased on interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 11 of 11 residents (R). Surveyor reviewed staff surveillance/call in list for three months and noted a certified nursing assistant (CNA) called in with symptoms of COVID-19 and returned to work without being tested. Surveyor noted 2 staff members had symptoms of COVID without reporting and turned out to be COVID positive while working. Facility does not provide laundry service for residents' personal laundry. Residents' families transport personal laundry home. Facility does not provide families with safe handling of laundry instructions for residents on contact precautions. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that each resident was treated with dignity and respect for 1 of 8 sampled residents (R62). R62 expressed concerns regarding CNA H (Certified Nursing Assistant) and requested CNA H not come in her room again. CNA H did not honor R62's request and repeatedly continued to enter R62's room. CNA H did not allow R62 to exercise her rights without interference. As evidenced by: The facility's policy and procedure, SNF (Skilled Nursing Facility)/Sub-Acute Resident Rights and Responsibilities, dated 3/17/23, states, in part, as follows: All staff members at all times recognize the rights of residents, and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care. As a resident of a nursing facility, you have extensive rights guaranteed under federal and state law. [...]

Inspectors wroteBased on record review and interview, the facility did not implement their written policy which includes completing background checks for 2 of 8 employees. PTA M (Physical Therapy Assistant) and RN N (Registered Nurse) background checks did not include a BID within the last 4 years. The facility policy Background Check, dated 7/16/20, contains the following information, in part: Procedure: After a conditional job offer for employment has been accepted by an applicant, the background check process will immediately begin. An electronic consent/disclosure (BID) form must be completed by the applicant prior to their start date and at least once every four years post hire . The Human Resources Department will initiate the collection of this electronic data through our background screening vendor. On 6/7/23, Surveyor reviewed eight personnel files. 1) PTA M's date of hire was 6/20/16. [...]