St. Dominic Villa

Inspectors wrote1 of 9 reviewed for bedrailsBased on interview and record review, the facility did not ensure other alternatives were tried prior to installing/utilizing bed rails, failed to accurately assess the risk of possible entrapment, failed to identify and recognize the use of an air mattress with bed rails increases the risk for entrapment, failed to re-assess and obtain an updated consent after the installation of an air mattress with bed rails, and care plan the need and use of bed rails for 1 of 9 residents (R11) reviewed for bed rails. R11 did not have alternatives attempted prior to the facility installing and utilizing bed rails. R11's bed rail assessment was not completed accurately. R11's bed rail assessment and consent form were not updated after the installation of an air mattress. R11's comprehensive care plan was not updated with the need and use of bed rails. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 59 residents. Visible dust was observed over a food preparation area. Food was improperly dated. Example 1On 12/9/25 at 11:01 AM, Surveyor observed, with DM E (Dietary Manager), the main kitchen's hood vents with visible clumps of dust on them and hanging off. Directly underneath the hood vents is a stove top and griddle where two pots of food were observed cooking. DM E was asked if he felt the hood vents were clean to which he replied, No, I can see some dust bunnies up there. [...]

Inspectors wroteBased on interview and record review, the facility did not provide behavioral health services to ensure the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 15 residents (R6) reviewed. R6 admitted to the facility with a history of post-traumatic stress disorder (PTSD). The facility failed to include PTSD on R6's comprehensive plan of care, nor were staff aware of any of R6's PTSD triggers. This is evidenced by: The National Institutes for Health states, in part: .PTSD can develop after exposure to a potentially traumatic event that is beyond a typical stressor. Events that may lead to PTSD include, but are not limited to, violent personal assaults, natural or human-caused disasters, accidents, combat, and other forms of violence. Exposure to events like these is common. [...]

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 for 1 of 1 wound care observations. Staff did not perform hand hygiene in between glove changes during wound care for R48. Evidenced by:The facility policy entitled Hand Hygiene, dated 12/5/2024, states, in part: . I. Policy: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. II. Procedure: A. Specific Indications for Hand Hygiene.4. After touching a patient or the patient's immediate environment.6. Immediately after glove removal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R36 and R8) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R36 was at risk for PI development. R36 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R36 had in place. The facility did not reposition R36 for several hours, did not find PI's until they were at a Stage 3, missed weekly wound treatments, and did not provide proper infection control measures during wound dressing change. R8 was at risk for PI development. R8 developed multiple stage 3 PI's. The facility failed to evaluate the effectiveness of current interventions R8 had in place. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents (R54). R54 was a known fall risk and the facility did not follow her plan of care, resulting in a fall with fracture.

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 59 residents. Food items were found undated or beyond their use by date in various locations in the facility. Staff were observed in the kitchen without hair nets.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was a system in place for standard transmission-based precautions to be followed to prevent the spread of infections. This had the potential to affect all 59 residents. The facility failed to do the following: The facility has one (2) resident's that tested positive for COVID 19. The facility did not complete contact tracing or broad-base testing of all residents to identify if others were COVID positive. The facility is only testing residents when they are symptomatic therefore the facility would have no way to know if they are in an outbreak due to not testing all residents. The facility is not utilizing source control on the affected unit. The facility does not have their agency staff N95 fit tested. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 59 residents residing in the facility. IP/ADON P (Infection Preventionist) and DON B (Director of Nursing) did not complete specialized training for infection prevention and control.

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 4 (LPN C, LPN W, Maintenance Supervisor X, RN V) of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when four employees' background information disclosure (BID) was not obtained before employees started working at facility. (LPN C, LPN W, Maintenance Supervisor X, and RN V).

Inspectors wroteBased on interview and record review, the facility failed to consult with the physician related to a significant change of condition for 1 of 7 residents (R46) out of 15 residents reviewed for physician notification. The facility did not consult with R46's physician after a culture and sensitivity (C&S) report confirmed he had a urinary tract infection. As evidenced by The facility's policy, Change of Condition and Provider Notification, reviewed 8/10/23, indicates, in part, the following: Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. Procedure: Change of Condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. Notification: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive assessment was completed for 1 (R21) of 7 residents reviewed for change of condition. R21 had an unresponsive episode, and the facility did not complete a full assessment or notify the physician (MD). R21 could not find his words the facility did not complete a full assessment or notify the MD. This is evidenced by: The facility utilizes Interventions to Reduce Acute Care Transfers, or Interact, as the facility's standard of practice. According to Interact II Signs and Symptoms to report immediately to a physician include: Consciousness, altered: Sudden change in level of consciousness or responsiveness. Speech Abnormality: Abrupt change in speech with or without other neurological findings. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 CNA T (Certified Nursing Assistant) of 5 staff reviewed for verification of a current Nurse Aide Registry were on the Wisconsin registry before starting work in the facility. CNA T was not on the Wisconsin Nurse Aide Registry and was working in the facility at the time of the discovery.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that its medication error rate was 5% or less for 39 medication pass opportunities and 1 of 3 sampled residents (R35) and 2 of 2 supplemental residents observed for medication pass (R18 and R31). The facility's medication error rate was 10.26% with four (4) errors observed for R18, R31, and R35. This is evidenced by: The facility policy, Medication Administration, revised December 2019, states in part, as follows: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration). [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure Residents are free of significant medication errors, for 1 of 1 supplemental resident's reviewed for significant medication errors (R31). Surveyor observed RN D (Registered Nurse) crush R31's Metoprolol extended release and administer it to R31. Evidenced by: The facility policy, entitled, Medication Administration - Medication Error, reviewed 6/13/23, states in part: Entity shall adhere to the rights of medication administration and review. Investigate, and document any medication error. The facility policy, Medication Administration, revised December 2019, states in part, as follows: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. FIVE RIGHTS: . right dose, . [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident's environment remains as free of accident hazards as possible for 1 of 1 residents (R1). R1 resided in the facility's memory care unit and has a history of tossing her leg onto the heat register next to her bed. On 1/15/24, R1 was found to have placed her foot on the heat register next to her bed. This resulted in burns to R1's left lateral foot (full thickness), left foot (undetermined thickness) and right foot (undetermined thickness) that required physician intervention. The facility does not routinely monitor the temperature of the heat registers. The facility's failure to provide proper safety interventions to prevent accidents and monitor resident's rooms and environment created a finding of Immediate Jeopardy that began on 1/15/24. [...]

Inspectors wroteBased on interview and record review the facility did not ensure physician orders were signed monthly for 1 of 1 Resident reviewed (R1). R1 did not have signed monthly orders for August 2023, September 2023, October 2023, November 2023, December 2023, or January 2024. This is evidenced by: R1 was admitted on [DATE]. R1 discharged on 1/26/2024. R1 had physician signed monthly orders dated 7/7/2023. No monthly signed physician orders noted in R1's medical chart for the following months: August 2023 September 2023 October 2023 November 2023 December 2023 January 2024 On 2/12/2024 at 11:47 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated the physician made rounds routinely and would include a review of medications in the physician progress notes. DON B indicated the physician progress notes do not specifically include all physician orders in the review. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 2 of 3 resident (R2 and R3). R2 required behavior health services that were not provided as indicated and recommended by R2's PASRR (Preadmission Screening and Resident Review). R2's care plan does not address R2's PTSD (post-traumatic stress disorder) and history of suicidal ideation and suicide attempts. R3's care plan does not address R3's OCD (obsessive compulsive disorder), history of suicidal behavior or history of physical and sexual abuse. Evidenced by: The facility policy titled, Comprehensive Person-Centered Care Plan, reviewed 8/10/23, states in part . I. Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 sampled Residents (R2). R2 had a change in condition that was not identified timely by nursing staff resulting in hospitalization for fluid overload. This is evidenced by: The facility policy entitled, 'Change of Condition and Provider Notification,' states in part: .Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. II. Procedure: 1. Change of condition. a) change of condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. [...]

Inspectors wroteOn 9/20/23 at 10:07 AM, surveyor interviewed CNA D (Certified Nursing Assistant) who indicated that there have been times she was not able to complete job duties, including baths, due to staffing. On 9/20/23 at 10:22 AM, surveyor interviewed LPN C (Licensed Practical Nurse) regarding staffing, LPN C stated, staff is very frustrated. LPN C indicated that CNA staff report to her that there in not enough time to get showers/baths completed. LPN C indicated there was times she was not able to perform wound care due to staffing issues. LPN C indicated nursing floor staff has to adjust the wound care schedules to allow for nursing floor staff to be able to complete all wound care. Based on observation, interview, and record review the facility failed to ensure that 5 of 13 sampled residents (R2, R10, R13, R9, R14) were free from neglect. [...]

Inspectors wroteExample 8 R14 was admitted to the facility on [DATE], and has diagnoses that include: morbid (severe) obesity, epilepsy, pain in left and right ankles and joints, gout (painful form of arthritis), and weakness. R14 Minimum Data Set (MDS) quarterly assessment, dated 7/24/23 indicates that R14 has a Brief Interview for Mental Status (BIMS) score of 15 indicating that R14's cognition is intact. R14 care plan, dated 4/48/23, with a target date of 10/22/23, states: .R14 is (at) risk for falls r/t (related to) gait/balance problems, incontinence . interventions include .The resident needs prompt response to all request for assistance . On 9/19/23 at 10:14 AM, Surveyor interviewed R14 regarding staffing. R14 stated that call light wait times are, Sometimes unacceptably long. R14 stated 5-6 times a week he is waiting for 45 minutes or more for his call light to answered by facility staff. [...]

Inspectors wroteBased on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director, or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all Residents residing within the facility. The facility did not have evidence all required attendees attended the QAPI meetings for the months of April 27, 2023 and August 17th, 2023. This is evidenced by: The facility policy entitled, Quality Assurance and Performance Improvement (QAPI), with a review date December 1, 2021, states, in part: . [...]

Inspectors wroteBased on interview and record review, the facility did not follow their grievance process for 2 of 14 Residents (R3 and R14). R3 voiced a grievance regarding lack of supplies, long call wait times, and staffing. R14 voiced a grievance regarding a staff member. Evidenced by: The facility policy titled, Grievance, with a reviewed date of 2/11/22, states, in part; Policy: Individual, guardian, and/or individual representative will be informed of the process to file a grievance or complaint and the facility's process to make prompt efforts to resolve grievances .B. Formal Grievance: .2. Grievance Officer will log all formal complaints onto the Grievance Tracking Log. Grievance Officer will provide a Quality Assurance designee with the written Grievance Form and keep a copy. Quality Assurance designee will assign a manager to complete the Quality Assurance Grievance investigation. 3. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that an alleged violation of neglect was reported to the State Agency (SA) and other officials immediately, but not later than 2 hours, after the allegation was discovered for 2 of 2 allegations involving residents (R2 and R19.) The facility was made aware R2 was found somnolent, with ants crawling in her bed and on her body. Staff were not able to report when she was last seen well. The facility failed to recognize this as potential neglect and failed to notify the State Agency and other officials. The facility failed to file a self-report to the State Survey Agency when R19 voiced an allegation of abuse on 10/4/23. This is evidenced by: The facility policy titled, Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, with a revision date of 12/1/22, indicates, in part: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations of neglect or mistreatment were thoroughly investigated to prevent further neglect for 1 resident (R2). The facility was aware R2 was found unresponsive with ants in her bed and covering her body. The facility has no evidence this was thoroughly investigated. This is evidenced by: R2 was admitted to the facility on [DATE] as a long-term resident to the memory care unit, with diagnoses that include, in part: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that, based on the comprehensive assessment of a resident, the residents receive treatment and care in accordance with professional standards of practice. This had the potential to affect 2 (R3 and R12) out of 4 residents reviewed for wound care. Surveyor observed staff not remove gloves after wound care and reorganize R3's room, not wash hands after removing soiled gloves, not wash hands between peri-care and wound care, and not wash hands between one wound and another. The facility did not ensure skin assessments were completed by qualified staff skin assessments failed to include wound measurements. The facility failed to inspect feet daily (diabetic foot checks daily) as indicated in R12's care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that a resident who entered the facility at risk for pressure injury (PI) development and/or is without a pressure injury does not develop pressure injuries, and receives the necessary treatment and services to prevent pressure injuries from developing, prevent infection, and to promote healing for 3 of 3 sampled residents (R10, R13, and R1). R10 has multiple stage 3 pressure injuries and is at high risk for more pressure injuries to develop. Surveyor observed R10 to be in the same position for over 5 hours without staff assisting in turning and repositioning. Surveyor observed R13 in the same position for over 3 hours and without staff assisting her with position changes and offloading. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure R9 (Resident) was provided with adequate supervision to prevent accidents, such as aspiration. This had the potential to affect 1 of 15 residents reviewed for accidents. R9 admitted to the facility on [DATE] with diagnoses including: pneumonia, dysphagia (a condition with difficulty in swallowing food or liquid), schizoaffective disorder, cerebral infarction, epilepsy, and history of traumatic brain injury. R9's Swallow Study, dated 3/23/23, includes Indication: Aspiration Pneumonia . Narrative and Impression: There is no evidence of aspiration though there is pooling in the vallecula. Pooling in the vallecula with some neuromuscular difficulty swallowing a pill. [...]

Inspectors wroteBased on interview and record review the facility did not maintain 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 for 1 of 13 sampled residents (R1) and 1 of 4 hand hygiene opportunities. Nursing and Housekeeping staff did not perform hand hygiene as indicated by professional standards. Example 1 The facility's policy, Hand Hygiene, reviewed 9/20/23, indicates the following: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. Specific Indications for Hand Hygiene: . 3. Before moving from work on a soiled body site to a clean body site on the same patient 3. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure the interdisciplinary team conducted periodic assessments to determine if self-administration of medications was safe and appropriate for 1 (Resident 14) of 2 residents reviewed who self-administered medication.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to ensure an injury of unknown origin was reported to the state agency for 1 (Resident 7) of 1 resident reviewed who had a fracture. Specifically, Resident 7 had a right femur fracture that was identified on 3/27/2023 and the origin of the injury was unknown. The injury was not reported to the state agency.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined that the facility failed to ensure an injury of unknown origin was investigated for 1 (Resident 7) of 1 resident reviewed for a fracture of unknown origin. Specifically, Resident 7 had a right femur fracture that was identified on 03/27/2023 and the origin of the injury was unknown. The injury was not investigated.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure colostomy care was addressed in comprehensive care plans for 2 (Resident 152 and Resident 7) of 2 residents reviewed who had colostomies, and failed to ensure hospice care was addressed in the comprehensive care plan for 1 (Resident 1) of 1 resident reviewed who was receiving hospice care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow appropriate infection control procedures during wound care for 1 (Resident 16) of 2 residents reviewed for pressure ulcer/injury.