Sheboygan Health Services

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 42 residents residing in the facility. The facility did not ensure food prep areas and equipment were in clean and sanitary condition. The facility did not have internal thermometers in the reach-in cooler and walk-in freezer to accurately monitor temperatures.

Inspectors wroteBased on staff interview and record review, the facility did not provide Pre-admission Screening and Resident Review (PASRR) services for 4 residents (R) (R23, R37, R1, and R6) of 5 sampled residents. The facility did not contact the state mental health authority when R23, R37, R1, and R6's PASRR Level I 30-day exemption expired or pursue further PASRR Level II screening.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure meals were served at regular times and in accordance with residents' preferences. This practice had the potential to affect more than 4 of the 42 residents residing in the facility. The facility consistently served meals later than posted mealtimes and residents' preferences.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R19) of 3 sampled residents. R19 was at risk for elopement and had an intervention for a WanderGuard. The intervention was not consistently implemented.

Inspectors wroteBased on staff interview and record review, the facility did not ensure weight monitoring was provided for 1 resident (R) (R7) of 5 sampled residents. R7's weights were not obtained using a consistent device and re-weights were not obtained for weight loss/gain of greater than 5 pounds (lbs). In addition, R7's physician and Power of Attorney (POA) were not notified regarding R7's weight loss/gain of greater than 5 lbs.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not serve meals consistently at regular meal times. This practice had the potential to affect more than 4 of the 36 residents residing in the facility. On 12/2/24, breakfast service started approximately 38 minutes after the posted meal time. Staff served the last breakfast tray 1 hour and 12 minutes after the posted meal time. On 12/2/24, lunch service started approximately 30 minutes after the posted meal time. Staff served the last lunch tray 1 hour and 16 minutes after the posted meal time.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain a home-like environment with a comfortable temperature for 1 resident (R) (R6) of 14 sampled residents. The heating/air conditioning unit in R6's room did not work which resulted in an inability to control the temperature in R6's room.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the state mental health authority was notified in a timely manner following a significant change in mental illness for 2 residents (R) (R7 and R22) of 5 sampled residents. R7 was admitted to the facility on [DATE] with a diagnosed mental illness with corresponding medication. The facility did not update and submit R7's Preadmission Screen and Resident Review (PASRR) Level I for additional Level II screening following changes to R7's medications. R22 was admitted to the facility on [DATE] with a diagnosed mental illness with corresponding medication. The facility did not update and submit R22's PASRR Level I for additional Level II screening following changes in R22's medications.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure oral care was consistently completed for 1 resident (R) (R3) of 14 sampled residents. Oral care was not consistently documented as completed, unavailable, or refused in R3's medical record.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents received the appropriate care and services to prevent urinary tract infections (UTIs). On 12/2/24, R2's uncovered nephrostomy tube drainage bag was observed on the floor.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R22) of 2 sampled residents received the necessary care and treatment for respiratory therapy. On 12/3/24, R22 received oxygen at a rate that was above the rate ordered by R22's provider.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R16) of 4 sampled residents. R16 had an order for Artificial Tears ophthalmic solution 1 drop per eye 3 times per day for dry eyes. R16 did not receive 16 doses of the scheduled medication and was told the medication was unavailable.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable temperature for 1 resident (R) (R18) of 1 sampled resident. On 12/2/24, Dietary Manager (DM)-G reheated a bowl of soup in the microwave and served the soup to R18 without checking the temperature. Approximately 14 minutes after being served, R18 indicated the soup was still too hot to eat.

Inspectors wroteBased on staff interview and record review, the facility did not ensure medical records contained accurate and complete documentation for 2 residents (R) (R16 and R31) of 14 sampled residents. R16's Medication Administration Record (MAR) indicated six doses of Artificial Tears were provided when the medication was unavailable for administration. R31 received dialysis three times per week. R31's medical record did not contain a physician's order for dialysis.

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 2 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure thorough and timely caregiver background checks were completed for Certified Nursing Assistant (CNA)-C and Maintenance Staff (MS)-D.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) and local law enforcement in a timely manner for 1 resident (R) (R3) of 4 sampled residents. On 9/11/24, R3 alleged staff pushed R3 to the floor. The facility did not report the allegation of abuse to the SA or local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R3) of 4 sampled residents. On 9/11/24, R3 alleged staff pushed R3 to the floor. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 3 residents reviewed for falls. R1 fell in the facility on 1/26/24. The root cause of the fall was not identified and R1's plan of care was not updated to prevent future falls.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form was completed in its entirety for 2 Residents (R) (R20 and R37) of 3 residents who remained in the facility when their Medicare Part A benefits ended. R20's SNFABN did not have a preference selected under the Options section of the form. R37's SNFABN did not have a preference selected under the Options section of the form.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an SCSA (Significant Change in Status Assessment) was completed for 1 Resident (R) (R19) of 13 sampled residents. The facility did not complete and submit an SCSA when R19 had a significant change on or about 8/15/23.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure adequate fall prevention interventions were in place for 1 Resident (R) (R1) of 3 sampled residents. The facility did not educate Certified Nursing Assistant (CNA)-C, who was new to facility, on the expected use of a gait belt during R1's transfers. R1's care plan did not contain an intervention for the use of a gait belt during transfers when R1 fell on 8/29/23.