Sauk Co Health Care Center

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 2 sampled residents (R46). R46 had a history of Foley catheter obstruction resulting in UTI (Urinary Tract Infection) and sepsis. On [DATE] - [DATE], staff observed and documented that R46 had decreased urine output, including no output on the NOC (overnight) shift on [DATE]. There is no evidence of provider notification of the overall decreased output and no evidence of increased monitoring or assessments by facility staff. On [DATE], R46 was transferred to the hospital and admitted to the ICU with due to an occluded Foley catheter, UTI, and septic shock. R46 expired at the hospital on[DATE]. [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 43 residents (R) in the facility. The facility staff infection control line list did not contain information regarding start of symptoms, resolution of symptoms, and testing which made it unclear if staff were excluded from work for an appropriate amount of time. The facility's monthly infection control rates were not segregated for specific infection types. This is Evidenced by: The facility policy, Infection Prevention and Control Program, dated 5/26, indicates, in part: Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 sampled residents (R2). On 12/10/25 staff observed and documented an open area on R2's left 5th digit. The facility did not complete an initial comprehensive assessment of the wound including, measurements, size and characteristics. On 12/19/25, R2 was sent to emergency department due to deterioration in the wound. R2 was diagnosed with a displaced fracture and osteomyelitis requiring antibiotic therapy. Evidenced by:According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. [...]

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 to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 residents (R2) reviewed for abuse. Facility became aware of an injury of unknown origin on 12/19/25 when R2 was sent to the emergency department and was found to have a closed nondisplaced fracture of the left pinky finger. The facility failed to report it to the state within the required timeframe. Evidenced by:The facility policy entitled Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 12/2025, states, in part: . Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 1 of 3 Residents reviewed (R2). Facility became aware of an injury of unknown origin on 12/19/25 when R2 was sent to the emergency department and was found to have a closed nondisplaced fracture of the left pinky finger. The facility failed to conduct and complete a thorough investigation. Evidenced by:The facility policy entitled Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 12/2025, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from Abuse. [...]

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 to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 2 of 3 residents (R1 and R2) reviewed for abuse. Facility became aware of an abuse allegation on 10/4/25 at 7:41 PM involving R1 and R2 The facility did not report the allegation to the State Agency. Evidenced by: The facility policy entitled, Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 10/2024, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an accusation of verbal abuse for 2 of 3 residents (R1 & R2) reviewed for abuse. Facility became aware of an abuse allegation on 10/4/25 regarding R1 and R2. The facility did not conduct a thorough investigation or put protections in place during the investigation. Evidenced by:The facility policy entitled, Reporting and Investigation of Alleged Caregiver Misconduct or Resident Rights Violation, dated 10/2024, states, in part: . Policy: It is the policy of the Sauk County Health Care Center that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, exploitation, corporal punishment or involuntary seclusion. Definitions: Definitions of Abuse and Neglect: .i. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 3 residents (R) reviewed for pressure injuries (R19). R19 was at risk for developing pressure injuries (PI) related to decreased mobility, bilateral above knee amputation, and radiation therapy. R19 developed a facility-acquired stage 3 PI. The facility did not identify or stage this as a PI but considered it a chronic wound, identifying the root cause was related to friction and shearing from the use of a slide board transfer. The facility continued to use the slide board transfer until after R19 had a EpiFix flap procedure to heal the PI. Additionally, R19 was known to use a rolled washcloth under his hip which the facility also identified as contributing to the PI. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not assure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional practices and include the expiration date when applicable for 1 of 2 medication rooms and 2 of 5 medication carts reviewed for compliance. Surveyor observed the following: -R25's PRN (as needed) Loperamide (27 capsules) expired 12/24. -R19's PRN Loperamide (4 capsules) expired 12/24. -R6's escitalopram (1 tablet) card expired 9/24. -3 boxes of blood glucose control solutions expired (7/27/23 & 3/1/25). -R9's Naproxen (7 tablets) PRN card expired 11/24. -6 stock insulin pens were expired: -1 Semglee expired 6/24. -2 Tresiba expired 12/31/23 & 11/30/24. -3 Basaglar expired 8/17/24 and 2 on 4/04/24. -Stock supply of Promethazine suppositories (6 suppositories) expired 10/24. Evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not implement policies and procedures to prohibit and prevent abuse for 1 of 8 staff reviewed for caregiver background checks. LPN G (Licensed Practical Nurse) was hired on 12/3/24 and had lived in one other state within the last three years. LPN G's background check information did not contain an out-of-state criminal background check. This is evidenced by: The facility's Prevention/Reduction of Resident Abuse, Neglect, Exploitation or Misappropriation of Property policy, revised 05/19 and reviewed 10/24, indicates in part: Employee Screening and Training .d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. The facility's Care Giver Background Investigations policy, reviewed/revised on 03/21/14, indicates in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident with a catheter receives appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (R25) reviewed for catheter care out of total sample of 17. Staff did not perform appropriate hand hygiene per Standards of Practice while providing catheter care. Evidenced by: The facility policy entitled. Hand Washing, dated 3/19/24, states, in part: . Purpose: -To cleanse hands to prevent the spread of potentially deadly infections -To provide a clean and healthy environment for residents, staff, and visitors -To reduce the risk to the healthcare provider of colonization or infections acquired from a resident Hand hygiene continues to be the primary means of preventing the transmission of infection. Policy: It is the policy of this facility that hand hygiene (HH) (e.g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 residents (R30 & R9) included in the medication pass task, which resulted in an error rate of 6.9%. R30 did not receive her ordered senna at the ordered time. R9 did not receive her ordered aspirin at the ordered time. Evidenced by: The facility policy entitled, Medication Pass, dated 2/2016, states, in part: .Policy: It is the policy of the [Facility name] that medications prescribed by the Physician will be administered accurately and timely. Procedure: .2. Read and compare the label on the drug with the MAR (Medication Administration Record) at least three (3) times- before, during and after preparing the drug .16. Be sure that you have the- A. Right Drug B. Right Dose C. [...]

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 5 residents (R4) reviewed for change of condition. R4 presented with a change of condition including decreased appetite (even her favorite foods), abdominal pain, fatigue, nausea, and vomiting. The facility failed to complete a GI (Gastrointestinal)/abdominal assessment and failed to notify R4's physician with R4's complaints of abdominal pain. R4 became lethargic and was transferred to the hospital and noted to have a perforated colon and pneumoperitoneum (the presence of air or gas in the abdominal cavity.) R4 was not a surgical candidate and returned to the facility on hospice services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for falls. On 9/2/24, R1 was in the shower room when CNA D (Certified Nursing Assistant) attempted to remove R1's incontinent product from under her while she was sitting in the shower chair. This caused R1 to begin to fall. CNA D and CNA E assisted R1 to the floor. When a nurse had not shown up for 15 minutes, CNA D & CNA E assisted R1 off of the floor prior to a nurse assessing R1 for any type of injury. From the fall incident on 9/2/24, R1 sustained a fracture to her right tib/fib. On 10/4/24, R1 had an x-ray completed that showed an angulated and displaced left femur fracture. R1 was sent to the hospital on [DATE] related to R1 now having an open fracture of the left femur. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was adequately monitored and that the drug regimen was free from adverse consequences for 1 of 1 resident (R2) reviewed for adequate monitoring. R2 has a diagnosis of Atrial Fibrillation (an irregular heartbeat, that occurs when the upper chambers of the heart beat rapidly and irregularly) and receives Coumadin (a blood thinner). R2 was prescribed Bactrim on 10/1/24. Antibiotics can potentiate the effect of Warfarin (Coumadin). The facility did not complete monitoring for symptoms of drug interactions. R2 was sent to the hospital after a fall and was found to have a supratherapeutic (high) INR (international normalized ratio, a lab that measures how long it takes the blood to clot) of 4.5. The therapeutic range for INR is 2-3. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 1 sampled residents (R12) out of a total sample of 17 residents reviewed. R12 developed a pressure injury in the facility. Over time, this pressure injury developed an odor, grew in size, and was noted to have an increase in drainage. The facility did not update R12's Medical Doctor (MD) with these changes. Surveyor observed R12 calling out, striking, and wincing in pain during wound care. Staff were unaware R12 had an order for as needed oxycodone to be given prior to wound care. [...]

Inspectors wroteBased on interview and record, the facility did not ensure that 4 of 4 sampled residents (R1, R12, R13, and R35) received treatment and care in accordance with professional standards of practice for foot care. The facility failed to provide diabetic foot checks daily in accordance with current standards of practice. The facility did not have a policy reflecting the current standards of practice related to diabetic foot checks. Evidenced by: Facility policy, entitled Skin Integrity-Foot Care, reviewed 4/2024, does not reflect current standards of practice related to daily diabetic foot checks completed by a nurse or someone with education to perform assessments. Per the American Medical Directors Association - The Society for Post-Acute and Long-Term Care Medicine. Pressure Ulcers. Clinical Practice Guideline, dated 12/9/14, includes, in part: [...]

Inspectors wroteBased on observation and interviews, the facility failed to serve food at an appetizing temperature. This has the potential to affect 2 of 17 sampled Residents (R32 and R3) and 2 of 3 supplemental Residents (R36 and R20). R3, R32, R36, and R20 voiced concerns that hot food was not always served hot and cold food was not served cold. 1 of the 2 test trays temped failed to meet appropriate temperatures. Evidenced by: The facility policy, Food Temperatures, with a revised date of, 4/2024, states, in part; .All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 F All cold food items must be maintained at served at a temperature of 41 F or below Example 1 On 4/18/24 at 8:01 AM, the kitchen delivered breakfast on B Hallway. Surveyor requested the last tray on the cart. Dietary Aide provided Surveyor the last tray. [...]