Milwaukee Catholic Home

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R4) of 6 sampled residents reviewed for transfers.*R4 was assessed and care planned to transfer with a sit to stand mechanical lift (EZ stand) and assist of 2 staff. Surveyor observed Certified Nursing Assistant (CNA)-C transfer R4 with the sit to stand mechanical lift without the assistance of another staff member.

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R4) of 1 sampled residents observed for incontinence cares. *Staff was observed not wearing appropriate personal protective equipment (PPE) while providing personal to R4. R4 was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was stored in a safe manner. This practice has the potential to affect all 22 residents located on the 2nd floor rehab unit. *The resident food refrigerators located in the medication (med) rooms have a desired temperature documented on the temperature log of 36 to 45 degrees Fahrenheit (F). The facility food storage policy documents that food refrigerators should be between 35 and 41 degrees. Surveyor observed the food refrigerator located in the 2nd floor Rehabilitation (Rehab) unit med room multiple times during survey. Surveyor observed the food refrigerator temp to be between 44 and 46 degrees on observations. The facility did not always document a temperature on the temperature log located in the 2nd floor Rehab med room.

Inspectors wroteBased Observation and interview, the facility did not ensure the tube feeding pole for 1 (R39) of 1 Residents reviewed for cleanliness of tube feeding equipment, had equipment that was clean and operating in a sanitary manner. Multiple observations were made of R39's tube feeding pole having dried tube feeding splatter and adhered debris to the screen, base of pole and cord.

Inspectors wroteBased on observation and interview the facility did not maintain infection prevention and control designed to reduce the transmission of disease and infection for 1 (R39) of 1 resident reviewed for bowel and bladder cares. *On 05/29/2025, Surveyor observed R39 with R39's tubing for their feeding tube under R39 while having a bowel movement, while on R39's bedside commode. Surveyor observed Licensed Practical Nurse (LPN)-G disconnect R39's tubing from R39's feeding tube port, remove the tubing from under R39, hang the tubing back on R39's tube feeding pole, then reconnect R39's tubing to R39's feeding tube port once R39 had returned to R39's chair. On 05/29/2025, Surveyor observed CNA-F clean R39 after a bowel movement, then handed R39 a washcloth with unchanged, dirty gloves, to clean R39's peri area. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure food was stored and prepared safely, in 1 (kitchen on 2nd floor) of 2 kitchens. This deficient practice has the potential to affect residents residing on 2 East who receive their meals from the second-floor kitchenette. *Cook-C used gloved hand to touch ready to eat food after touching multiple surfaces.

Inspectors wroteBased on interview and record review the Facility did not notify a Resident's representative and attending physician when there was a change of condition involving 1 (R25) of 20 residents reviewed for notification of a representative. * R25 developed a stage 2 pressure injury to the left heel. There was no documentation R25's representative or attending physician were updated when the change of condition occurred.

Inspectors wroteBased on observation, interview and record review the facility did not revise resident care plans for 2 (R84 and R25) of 20 resident care plans reviewed. *R84 developed a facility acquired stage 3 pressure injury to the right buttock. R84's care plan was not revised to include interventions for the stage 3 pressure injury. *R25 developed a facility acquired stage 2 pressure injury to the left heel. R25's care plan was not revised to include interventions for the stage 2 pressure injury.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 of 9 (R25) residents reviewed for pressure injuries. * R25 did not have a comprehensive assessment with measurements or treatment put in place when a new stage two pressure ulcer of left heel was discovered on 1/29/2024 and was missing weekly assessments and measurements for 10 days until 2/8/2024. R25 was observed to not have heels supported off the bed or heel boots on during this time.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 2 (R14 and R46) of 3 residents reviewed received dialysis services consistent with professional standards of practice. * R14 was admitted to the facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. There was no communication between the facility and the dialysis facility with each visit. * R46 did not have a physician's order documenting the frequency of dialysis treatments or the location of the dialysis center in the community. There was no communication between the facility and the dialysis center with each visit.

Inspectors wroteBased on record review and interview, the Facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action taken to address the identified concerns. This was observed with 1(R14) of 5 residents reviewed for medication regimen review. * R14 did not have monthly Pharmacy Medical Record Reviews completed and recommendations reviewed by the attending physician or Medical Director.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R82 and R14) of 3 resident were free from PRN (as needed) psychotropic medications. * On 12/28/23 R82 was prescribed Lorazepam (anti-anxiety medication) 1 mg every two hours PRN without a stop date. * On 10/17/23 R14 was prescribed Lorazepam 0.5 mg twice daily PRN without a stop date.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure a resident received routine dental services for 1 (R1) of 1 resident reviewed for dental services. The facility did not arrange routine dental services for R1.