Onalaska Care Center

Inspectors wroteBased on interview and record review, the facility did notify the resident representative of a change in condition for 1 of 3 residents (R) reviewed (R1). R1 had multiple syncopal episodes resulting in one fall, and R1's family/representative was not notified for each occurrence. This is evidenced by: Facility policy titled, Change in Condition, with a revised date of 08/12/24, states in part: Purpose: To assure appropriate medical intervention in the event of significant change in resident's physical or mental condition. Procedure: .3. The Charge Nurse will assess the resident and will immediately consult with the provider and notify the family/HCPOA when a deviation occurs, including: i. An accident, which results in an injury and has potential for requiring physician intervention. 2. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents received care and treatment in accordance with professional standards of practice for 1 of 3 residents (R) reviewed (R1). Staff did not complete comprehensive and focused respiratory, skin and pain assessments after R1 had a fall and complained of rib pain. This is evidenced by: Facility policy titled, Resident Fall, with a revised date of 01/06/25, states in part: .After immediate/emergent needs have been addressed, head-to-toe assessment of resident to be performed by the RN/Charge LPN including assessment for head trauma, any obvious injury, pain, possible fracture, ability to move all extremities, any deformity/shortening/rotation of legs. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This has the potential to affect all 53 residents who reside in the facility. Facility staff did not conduct appropriate hand hygiene and were observed touching ready to eat foods with contaminated gloved hands. This is evidenced by: Facility's policy Handwashing and Sanitizing with the recent effective date of 10/28/24 read in part, Handwashing/Sanitizing indications: .after removing gloves .Handwashing: Wet hands thoroughly with warm running water. Soap hands thoroughly, working up a lather. Wash all parts of hands for 20 seconds. Rinse hands thoroughly. Leave the water running. Dry hands with paper towels. Turn off faucet with dry paper towel . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff. The facility did not ensure an adequate surveillance system was in place for tracking onset of illness date and resolution of illness symptoms resulting in an outbreak to be lifted prematurely or identify communicable diseases on the line list for R29 and R19. Staff did not practice proper hand hygiene during observation of cares for 4 of 9 residents (R) (R25, R28, R13, and R153). Enhanced barrier precautions were not in place for R14 or followed for R19 Staff did not sanitize a mechanical lift during observation of transfers of 2 residents (R25 and R28) who are roommates. This is evidenced by: [...]

Inspectors wroteBased on policy review and interview, the facility failed to ensure facility's admission packet did not request or require residents to waive potential facility liability for losses of personal property. This failure had the potential to affect all 53 residents residing in the facility. This is evidenced by: Facility document titled, Personal Property Notice, stated in part: Residents of any [corporation name] facility may have in their possession whatever personal property they choose within reason and in keeping with space limitation, infection control concerns and safety issues for all residents and staff. HOWEVER, please be aware that [corporation name] is not responsible for the loss, damage or maintenance of any personal possessions or property. [...]

Inspectors wroteBased on observation and interview the facility failed to distribute food under sanitary conditions; improper glove use, food handling without proper hand hygiene. This has the potential to affect all 48 residents who reside in the facility. This is evidenced by: The facility policy and procedure entitled, Hand Washing, updated 06/21/21 states in part, Hands shall be washed immediately before engaging in food preparation . After handling soiled equipment or utensils, During food preparation, as often as necessary to remove soil and contamination when changing tasks. When switching between working with raw food and working with ready to eat food, before donning gloves for working with food. On 12/04/23 at 11 AM, Surveyor observed noon meal service in the main dining room. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure 1 of 1 (R5) resident reviewed for respiratory care received the necessary care of respiratory equipment consistent with the comprehensive person-centered care plan. R5 had no respiratory care plan or parameters for changing the oxygen tubing or humidified water reservoir. This is evidenced by: The facility policy, entitled Oxygen Procedures, dated 12/06/23, states: .Concentrator Maintenance: .Once a week replace oxygen tubing and humidified water - document change in TAR . R5 was admitted to the facility on [DATE], and has diagnoses that include in part cough, shortness of breath, anxiety disorder, panic disorder, and obstructive sleep apnea (OSA). R5's Minimum Data Set (MDS) assessment, dated 09/18/23, indicated respiratory treatments of oxygen therapy. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection control program to prevent the spread of infections for 1 of 1 (R28) resident on contact precautions and 1 of 1 (R5) reviewed with a urostomy. This is evidenced by: The facility policy, entitled Isolation Guidelines Transmission-Based precautions, dated 11/06/23, states: In addition to standard precautions, use contact precautions to prevent nosocomial spread of organisms that can be transmitted by direct contact (hand or skin-to-skin contact that occurs when performing resident care) or by indirect contact (touching) of environmental surfaces or contaminated resident care equipment and Contact precautions may be considered for residents who have: 1. [...]