Soldiers Grove Health Services

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 13 sampled residents (R20) resulting in actual harm. R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide an assessment completed by an RN (Registered Nurse) or with RN oversight at the time of the fall. The facility failed to notify the physician timely of the fall, failed to relay all of R20's symptoms to physician and DON B (Director of Nursing) at the time of the fall, and failed to notify physician of changes of condition following the fall. R20 was found to have a left acetabular (hip joint socket) fracture. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R20) reviewed for falls resulting in actual harm. R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide temporary interventions to address the self-transferring. R20 was found to have a left acetabular (hip joint socket) fracture. This is evidenced by:Facility policy, titled Fall Prevention and Management Guidelines, reviewed and revised on 7/18/24, states in part; Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. [...]

Inspectors wroteNumber of residents sampled:34Number of residents cited:34Based on record review and interview, 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 34 residents who reside in the facility. The facility's dishwasher was not reaching appropriate temperatures.

Inspectors wroteNumber of residents sampled:34Number of residents cited:34Based 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 the census of 34 residents. The facility has not established a line list that reflects resident's symptoms, lab results, symptom onset date, and the type of infection a resident has. Evidenced by: The facility's policy titled Infection Surveillance dated 3/8/23 states in part .1. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 1 resident reviewed for grievances (R13). R13 expressed concerns regarding asking for assistance with ADLs (Activities of Daily Living) that was not completely investigated by the facility. Evidenced by: The facility's policy titled Grievance Policy dated 7/2022 states in part .When a Complaint/ Grievance Report is initiated: .The original form will then be forwarded to the department head for which the Grievance pertains to (i.e. Dietary Manager for food and dining related issues, DON (Director of Nursing) for any nursing or clinical related issues.). The Department Head that is assigned the concern form is responsible for investigating the issue within 72 hours of being assigned the grievance. The Grievance Officer will ensure: [...]

Inspectors wroteNumber of residents sampled:1Number of residents cited:1Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 1 resident (R8) reviewed. The facility does not provide R8 with specialized services per PASAAR Level 2 recommendations. Evidenced by:Per the facility, they do not have a PASRR Policy and Procedure. According to Wisconsin Department of Health Services at https://www.dhs.wisconsin.gov>pasrr, states, in part: . Preadmission Screening and Resident Review (PASRR) is a federal requirement established to identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement in the community or a nursing facility. [...]

Inspectors wroteNumber of residents sampled: 12Number of residents cited:1Based on interview and record review the facility did not develop a comprehensive care plan or review and revise the comprehensive care plan for 1 of 12 sampled residents (R13). R13's care plan did not address the type of assistance required for dressing. Evidenced by:The facility's policy titled Comprehensive Care Plan revised on 9/23/22 states in part .1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well- being. [...]

Inspectors wroteNumber of residents sampled:2Number of residents cited:1Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 2 residents (R4) reviewed for nutrition of a total sample of 13 residents. R4 had a severe weight loss of 11.29% in 6 months. The facility did not put interventions into place to prevent weight loss or update the physician during the 6-month period. Evidenced by:The facility policy entitled Weight Monitoring, dated 12/21/22, states, in part: . Policy: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents. Procedure:Weight Assessment.7. The dietician will review the monthly weights to follow individual weight trends over time. [...]

Inspectors wroteNumber of residents sampled:7Number of residents cited:3Based on interview and record review, the facility does not follow a nationally recognized standard of practice for infection control or monitoring antibiotic use, and they do not have protocols in place to obtain cultures and other reports to ensure residents are receiving the correct antibiotic for 2 of 7 residents (R30 and R25) reviewed for infections. R30 was started on an antibiotic and had no documented signs of an infection. R25 received orders for a UA (Urinalysis) without meeting criteria and was subsequently placed on an antibiotic. Evidenced by: The facility's policy titled Antibiotic Stewardship Program revised on 11/18/22 states in part .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately consult with the resident's physician when there is a need to alter treatment for 1 out of 3 residents (R) reviewed for physician notification (R1). R1 had a change of condition and the facility failed to update the physician. R1 had an oxygen saturation level outside of parameters on several occasions and the physician was not updated. Facility staff also increased R1's oxygen without updating the physician or receiving orders to increase oxygen. This is evidenced by: Facility policy, titled, Change in Condition of the Resident, last reviewed 9/20/22, states in part . Policy: A facility should immediately inform the resident; consult with the resident's physician; [...]

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility did not develop and implement a comprehensive resident-centered care plan for 1 of 5 sampled residents reviewed (R2). R2 has a history of making false allegations. This is not on R2's comprehensive care plan. Evidenced by: The facility's Comprehensive Care Plan policy, dated 9/23/22, includes, in part, the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: f. [...]

Inspectors wroteBased on observation and interview, the facility failed to distribute food under sanitary conditions, did not utilize proper glove use and handled food without proper hand hygiene. This has the potential to affect all 35 residents who reside in the facility. This is evidenced by: The facility policy and procedures for Healthcare Services Group entitled, Infection control overview & Policy, states in part, Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. The policy also states food should be labeled and dated with a prepared date and a use by date. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 07/01/23-12/31/23 (Quarter 4 2023 and Quarter 1 2024) was complete, accurate, and auditable. This can affect all 35 residents residing in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Excessively Low Weekend Staffing and One Star Staffing Rating from 07/01/23-12/31/23 (Quarter 4 2023 and Quarter 1 2024). There were no specific dates listed. Surveyor reviewed the facility's time sheets for weekends in the months in question and found adequate staffing on all weekends. Surveyor reviewed the facility's Daily Schedule sheets for the months of October 2023 to December 2023 and did not find any weekends that had low weekend staffing concerns. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (R21).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure assessments for bowel continence and interventions to maintain current bowel continence were implemented to maintain bowel function for 1 of 1 resident reviewed with a bowel incontinence (R25). This is evidenced by: R25 was admitted to the facility on [DATE] and has diagnoses that include neurogenic bladder, acute pyelonephritis, diabetes mellitus type 2 and mild intellectual disability. R25's Minimum Data Set (MDS), dated [DATE], indicates that R25 has a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete interview), an indwelling Foley catheter, bowel continence of not rated, uses a Hoyer lift for transfers and is dependent on staff for bowel continence. R25's MDS, dated [DATE], indicates that R25 has bowel continence rated at 02: frequently incontinent. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a care plan was developed for nicotine use for 1 of 2 residents (R) 1 reviewed for comprehensive care plans. This is evidenced by: The facility policy, entitled Comprehensive Care Plan dated 09/23/22, states in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The facility did not assess the resident's ability to use e-cigarettes after determining that the resident used nicotine products. This occurred for 1 of 2 residents (R) 1 reviewed for assessments related to nicotine use. This is evidenced by: The facility policy, entitled Smoking Policy dated 07/14/22, states in part: This center shall establish and maintain a safe resident environment, while maintaining resident rights, smoking or nicotine use will be limited to designated areas, supervision and safety plans . 1. Residents who smoke or use smokeless tobacco products shall have a Nicotine Assessment completed upon admission, quarterly, annual and PRN. Residents or responsible party must be in agreement to nicotine use . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure Residents (R2 and R3) with pressure injuries/ulcers receives necessary treatment and services consistent with professional standards of practice to prevent infection for 2 of 3 residents reviewed for pressure injuries. LPN C (Licensed Practical Nurse) did not perform appropriate hand hygiene while providing wound care to R2. LPN D did not perform appropriate hand hygiene while providing wound care to R3. This is evidenced by: Facility policy 'Clean Dressing Change,' states in part: Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 5. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents' receive treatment and care in accordance with professional standards of practice, for 1 of 17 sampled residents (R42). R42's Nurse Notes reflect a change in his condition. Facility staff failed to assess R42 during a change of condition, failed to update R42's Medical Doctor, and failed to update R42's Responsible Party. Evidenced by: Facility policy entitled Change in Condition of Resident, reviewed 9/20/22, includes, in part: When a resident presents with a possible change in condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: assess the resident's need for immediate care/medical attention. Provide emergency care as needed. Assessment/evaluation could include, but is not limited to, the following: [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure adequate monitoring for medications with a black-box warning for 1 of 5 Residents reviewed for unnecessary medications out of a total sample of 17 Residents (R35). R35 receives Depakote, Keppra, and Trileptal for seizure activities. All 3 of these medications have black-box warnings. R35 was not being monitored for side effects or for effectiveness of these medications by a licensed nurse. Black box warnings, are required by the U.S. Food and Drug Administration for certain medications that carry serious safety risks. Often these warnings communicate potential rare but dangerous side effects, or they may be used to communicate important instructions for safe use of certain drugs. This is evidenced by: Facility policy entitled 'Medication Monitoring Medication Management,' dated 01/23, states in part: . [...]

Inspectors wroteExample 2: The facility's policy titled Psychotropic Medication states the following: *A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Syntrophic drugs include but are not limited to the following categories: anti psychotics, antidepressants, anti anxiety, and hypnotics. * The indications for initiating, withdrawing, or withholding medications, as well as the use of non pharmacological approaches, will be determined by assessing the residents underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. * The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication liberation residents, their families and/or representatives about professionals, interdisciplinary team. [...]