Stevens Point Health Services

Inspectors wroteBased on staff interview and record review, the facility did not ensure the State Long-Term Care Ombudsman was notified of transfers or discharges for 4 residents (R) (R41, R43, R5, and R6) of 4 sampled residents. R41 was transferred to the hospital on 7/1/25. The Ombudsman was not notified of the transfer. R43 was discharged home on 5/2/25. The Ombudsman was not notified of the discharge. R5 was transferred to the hospital on 5/9/25. The Ombudsman was not notified of the transfer. R6 was transferred to the hospital on 1/29/25, 3/17/25, and 6/15/25. The Ombudsman was not notified of the transfers.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R3 and R34) of 5 sampled residents had documentation that indicated the residents or their legal representatives were informed in advance of the risks and benefits of prescribed medications. R3 was prescribed divalproex sodium (Depakote) (an anticonvulsant medication) and clindamycin phosphate external solution 1% topical (an antibiotic medication). Verbal consent for the medications was received from R3's activated Power of Attorney for Healthcare (POAHC), however, written consent was not obtained. [...]

Inspectors wroteBased on staff interview and record review, the facility did not monitor for adverse consequences or the effectiveness of psychotropic medication for 1 resident (R) (R44) of 6 sampled residents. The facility did not monitor for adverse consequences or the effectiveness of trazadone (an antidepressant medication) and sertraline (an antidepressant medication) for R44.

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures that prohibit and prevent abuse for 1 (Registered Nurse (RN)-I) of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough and timely caregiver background check was completed for agency RN-I.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the comprehensive plan of care was revised in a timely manner for 1 resident (R) (R6) of 1 sampled resident. R6's care plan was not revised after R6 was readmitted from the hospital on 3/20/25 and 6/23/25 with diagnoses of sepsis/urosepsis (urinary tract infection (UTI) that spreads to the blood stream).

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R5) of 3 sampled residents. R5's continuous positive airway pressure (CPAP) and oxygen equipment were not cleaned and replaced in accordance with orders on R5's Treatment Administration Record (TAR).

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure accurate order transcription and medication administration for 1 resident (R) (R5) of 2 sampled residents. On 7/22/25, R5 was administered 81 milligram (mg) of enteric coated (EC) aspirin which differed from R5's order. In addition, the wrong dose of fluticasone propionate was administered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R5) of 4 residents observed during the provision of cares. R5 was on enhanced barrier precautions (EBP). On 7/21/25, staff did not follow EBP during high-contact cares for R5.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a medication cart was locked when unattended. This practice had the potential to affect more than 4 of the 38 residents residing in the facility. On 6/13/25, Surveyor observed an unattended and unlocked medication cart on the second floor by the nurses' station. Two residents were in the vicinity.

Inspectors wroteBased on observation, staff, resident, and resident representative interview, and record review, the facility did not ensure food preferences were accommodated and/or individualized meal tickets were followed for 10 residents (R) (R1, R4, R6, R7, R9, R10, R11, R12, R13 and R14) of 16 sampled residents. Staff did not follow R1's individualized meal ticket on 6/13/25. Staff did not provide item listed on R4's individualized meal ticket on 6/13/25. Staff did not ensure R6, R7, R9, R10, R11, R12, R13 and R14 received drinks as indicated on their individualized meal tickets for lunch on 6/13/25.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure proper footwear was worn during a mechanical lift transfer for 1 resident (R) (R17) of 1 sampled resident. R17 had diabetes and was at risk for foot injury. Staff did not ensure R17 wore proper footwear when they transferred R17 with a sit-to-stand lift.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide adaptive eating equipment for 1 resident (R) (R5) of 16 sampled residents. Staff did not provide R5 with lidded cups and a divided plate per R5's meal ticket.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R17) of 2 residents observed during the provision of care. Staff did not ensure enhanced barrier precautions (EBP) were followed for R17 during high-contact cares.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure an allegation of abuse/neglect was reported to the State Agency (SA) in a timely manner for 1 resident (R) (R2) of 11 sampled residents. R2 and R2's family member reported an allegation of abuse/neglect to staff. The facility did not report the allegation to the SA.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure all allegation of abuse/neglect was thoroughly investigated for 1 resident (R) (R2) of 11 sampled residents. The facility did not thoroughly investigate on allegation of abuse/neglect reported by R2 and R2's family member.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to promote healing and/or prevent pressure injuries from developing for 1 resident (R) (R1) of 2 sampled residents. R1 was admitted to the facility with a pressure injury (PI) on the left heel. The facility did not complete accurate assessments of R1's left heel PI.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R9, R6, and R5) of 7 residents observed during medication administration and the provision of care. During observations of medication administration for R9, R6, and R5, Medication Technician (MT)-C and Licensed Practical Nurse (LPN)-D did not complete appropriate hand hygiene. MT-C and LPN-D did not adhere to contact precautions during medication administration for R6 and R5.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure a resident representative was notified of a change in condition for 1 resident (R) (R1) of 4 sampled residents. R1 experienced an overall decline including changes in transfer ability and eating habits during November and December of 2024. The changes were not communicated to R1's court-appointed Guardian.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not consistently monitor nutrition intake for 1 resident (R) (R1) of 4 sampled residents. R1 experienced a significant weight loss. Staff did not consistently monitor or document R1's meal intake to determine if nutritional interventions were effective.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R1 and R3) of 3 sampled residents received the necessary care and services to prevent and heal pressure injuries. R1 was admitted to the facility following a fall with fractures and had bilateral splints to the lower extremities. The splints were not removed for skin checks and R1 developed an unstageable deep tissue injury (DTI) on the right heel. In addition, R1 had a pressure injury on the sacrum that was allegedly present upon admission on [DATE]. Treatment was not initiated until 10/4/24 and air mattress was not ordered until 10/11/24. R3 was admitted to the facility on [DATE] with a pressure injury on the left heel. A wound assessment and treatment order were not obtained until 5/15/24. [...]

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility did not ensure proper infection control practices were maintained related to the use of personal protective equipment (PPE) for 2 residents (R) (R2 and R3) of 2 residents who were on enhanced barrier precautions (EBP). R2 was on EBP due to urinary concerns. Staff did not don the appropriate PPE during the provision of high-contact care for R2 on 11/5/24. R3 was on EBP due to wounds and colonized bacteria in R3's urine. Staff did not don the appropriate PPE during the provision of high-contact care for R3 on 11/5/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure bathing assistance was provided for 1 Resident (R) (R1) of 4 sampled residents. R1 did not receive 3 of 10 scheduled showers between the dates of 4/23/24 and 7/10/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure accurate administration of medication for 1 Resident (R) (R1) of 4 sampled residents. R1 did not consistently receive pain medication timely or accurately as ordered by R1's physician.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This practice had the potential to affect all 42 residents residing in the facility. Dietary Manager (DM)-H did not complete an approved dietary manager or food service manager certification course or other related education.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 42 residents residing in the facility. Staff did not complete hand hygiene after washing dishes and prior to touching ready to eat food. The counter was not in clean condition when staff cut vegetables. The microwave was not in clean condition and the mixer was not covered. Staff did not maintain unit refrigerator and freezer temperature logs. Open items in the walk-in cooler and dry storage area did not contain open dates.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the designated Infection Preventionist (IP) completed infection prevention and control training and was employed at least part-time in the facility. This practice had the potential to affect all 42 residents residing in the facility. The facility's designated IP did not work in the facility at least part-time.

Inspectors wroteBased on observation and staff interview, the facility did not ensure the right to personal privacy for 1 resident (R) (R21) of 19 sampled residents. During an observation on 5/6/24, staff did not ensure R21 had visual privacy and dignity during personal care.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate fall prevention interventions were in place for 3 residents (R) (R36, R10, and R291) of 3 sampled residents. R36 fell on 3/14/24 and 3/18/24. The facility did not implement new fall interventions to prevent future falls. R36 fell again on 3/22/24. R10 was admitted to the facility following a fall with a fracture at home. R10 had a rug in R10's room with curled edges. The facility did not develop a comprehensive falls care plan, including R10's preference and risk for keeping the rug in R10's room. R291's smoking materials were to be stored securely by staff. During an observation on 5/7/24, smoking materials were observed in R291's room.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 2 residents (R) (R8 and R144) of 2 residents reviewed for oxygen therapy. R8 used humidified oxygen from a concentrator. R8 did not have a physician's order for oxygen use. In addition, R8's care plan did not address oxygen use and R8's oxygen tubing was not labeled to indicate the date the tubing was last changed. R144 used oxygen from a concentrator. R144 did not have a physician's order for oxygen use or a care plan that addressed the use of oxygen.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmacy services in accordance with the wishes of a resident/legal representative when the facility administered vaccines to 1 resident (R) (R11) of 5 sampled residents who declined the vaccines. The facility administered COVID 19 and influenza vaccines to R11 after R11 declined the vaccines.

Inspectors wrote3. On 5/8/24 at 11:02 AM, Surveyor observed CNA-P and CNA-Q provide care for R27. After performing hand hygiene and donning gloves, CNA-P and CNA-Q assisted R27 onto the commode via EZ stand. CNA-P removed R27's incontinence brief which was soiled with a small amount of stool. CNA-P performed hand hygiene, donned clean gloves, and washed R27's perineal area. Following perineal care, CNA-P did not remove gloves, cleanse hands, and don clean gloves before CNA-P touched R27's clean brief, clothing, wheelchair, and the EZ stand lift. On 5/8/24 at 11:10 AM, Surveyor interviewed CNA-P who verified CNA-P did not remove soiled gloves and perform hand hygiene after completing pericare and before touching the items mentioned above. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 3 residents (R) (R7, R11, and R21) of 5 residents reviewed for vaccines. The facility did not offer R7 the PCV20 (Prevnar 20®) vaccine. The facility did not offer R11 the PCV20® vaccine. The facility did not offer R21 the PCV20® vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the minimum required members of the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly. This practice had the potential to impact all 42 residents residing in the facility. The facility did not hold two of four required QAPI meetings in the past year or six of twelve monthly meetings per their policy. For the two required QAPI meetings held, the facility was unable to provide verification of attendance for the required members.

Inspectors wroteBased on staff interview and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R91) of 1 resident reviewed for pain management. R91 was not provided effective pain management in a timely manner on 3/18/24.

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 5 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 Maintenance Director (MD)-C, Certified Nursing Assistant (CNA)-D, CNA-E, CNA-F, and Occupational Therapist (OT)-G.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a potential allegation of abuse was reported to the State Agency (SA) for 1 Resident (R) (R1) of 8 sampled residents. R1 expressed fear of the care provided by Certified Nursing Assistant (CNA)-E following an incident on 1/31/24. The potential allegation of abuse was not reported timely to Nursing Home Administrator (NHA)-A and was not reported to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a potential allegation of abuse was thoroughly investigated for 1 Resident (R) (R1) of 8 sampled residents. R1 expressed fear of the care provided by Certified Nursing Assistant (CNA)-E following an incident on 1/31/24. The potential allegation of abuse was not thoroughly investigated.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a provider or Power of Attorney for Healthcare (POAHC) were notified following falls for 2 Residents (R) (R3 and R14) of 2 sampled residents. The facility did not notify R3's provider following two of three falls on 9/1/23. The facility did not notify R3's POAHC following any of the falls. The facility did not notify R14's provider or POAHC following falls on 9/5/23, 9/17/23, and 11/27/23.

Inspectors wroteBased on record review and staff and resident interview, the facility did not make a prompt effort to thoroughly investigate and resolve a grievance for 1 Resident (R) (R2) of 14 sampled residents. On 8/6/23, R2's Power of Attorney for Healthcare (POAHC) sent an email to the facility that expressed multiple concerns regarding R2's care. The facility did not thoroughly investigate or provide resolution of the grievance.

Inspectors wroteBased on staff interview and record review, the facility did not ensure fall assessments were completed and care plan interventions to prevent falls were added/updated for 2 Residents (R) (R3 and R14) of 2 sampled residents. The facility did not appropriately assess R3 following three falls on 9/1/23. In addition, the facility did not investigate the circumstances surrounding the falls or update R3's care plan with interventions to prevent future falls. The facility did not appropriately assess R14 following falls on 9/5/23, 9/17/23, and 11/27/23. In addition, the facility did not investigate the circumstances surrounding the falls or update R14's care plan with interventions to prevent future falls.

Inspectors wroteBased on record review and interview, the facility did not provide opportunities for residents and/or their legal representatives to participate in their care planning process when changes were made during the assessment and care planning process. This has the potential to affect 5 of 9 sampled residents. (R14, R2, R20, R19 and R22). Sampled residents R14, R2, R20, R19 and R22 were not provided the opportunity to participate in their care planning process when Minimum Data Set (MDS) assessments prompted changes to the plan of care.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure timely physician visits were being conducted for four residents (R9, R10, R2 and R16). - R9 was hospitalized [DATE]- 5/28/22. From 5/28/22 through next hospital stay of 1/13/23 - 1/1/7/23 there have been no face-to face visits from a physician with the exception of Dermatology. R9 was again sent to the Emergency Department 3/1/23 and returned that evening. - R10 was admitted [DATE] and to date, has not yet been seen by a medical physician. - R2 was not seen by a physician from 8/8/22 until present. - R16 was admitted [DATE]. There is no record that R16 has yet been seen by a physician. This is evidenced by: [...]

Inspectors wroteBased on record review and interview, the facility did not obtain written consent explaining the risks and benefits of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (R19). R19 is prescribed risperdal, an antipsychotic medication for agitation related to dementia with lewy bodies, and buspirone, an antianxiety medication for general anxiety. The facility did not have a written, signed consent explaining the risks and benefits of to R19's power of attorney (POA). This is evidenced by: Surveyor reviewed R19's current physician orders and noted R19 is currently ordered the following: ~3/29/23: Buspirone 15 mg tid for general anxiety ~2/03/23: Risperdal 0.25 mg every day for agitation related to dementia with lewy bodies Surveyor noted although there were dose changes, the Buspirone was initiated on 2/16/23 and the Risperdal was initiated on 8/13/21. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not complete and implement baseline or comprehensive care plans (CP) for 1 of 3 Residents (R 79), within 48 hours of admission, that included instructions on how to provide effective and person-centered care for the resident. Surveyor reviewed R79's medical record and was unable to locate a baseline or comprehensive CP that would have been dated within the first 48 hours of admission. The CP was first developed 4/11/23 or four days following admission. This is evidenced by: The facility policy titled Baseline Care Plan was dated 9/22/22 and included the following directives to staff: .1. The baseline care plan will be developed within 48 hours of a resident's admission and will include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. [...]

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility did not ensure staff consistently provided necessary services to maintain good grooming and toileting needs for 2 of 4 residents (R25 and R79) sampled. - R79 indicated a long call light response, and as a result of the lengthy time in which to receive care, had a large incontinent bowel movement in her pants. - Random observations were conducted in which R25 had long whiskers on her chin, which were bothersome to her and she requested multiple times to have them tended to. This is evidenced by: Example 1 R79 was admitted to the facility 4/7/23, following hospitalization after a fall at home in which she sustained a Displaced Fracture of the Second Vertebra, multiple fractures of right sided ribs, a Left-Sided Cervical 2 fracture and a Traumatic Hemopneumothorax. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 2 of 15 (R9 and R19) residents reviewed, received treatment and care in accordance with professional standards of practice. - R9's physician orders were not followed related to labwork requested. - R19 has not gotten out of bed for several weeks due to his poor positioning in his wheelchair. Example 1 R9 had medical diagnoses that included, but were not limited to Acute Pancreatitis without Necrosis or infection, Muscle Weakness, Diabetes Mellitus Type II, Major Depressive Disorder, Generalized Anxiety Disorder and Post-Traumatic Stress Disorder. According to the most recent Minimum Data Set Assessment, which was a quarterly assessment dated [DATE], R9 required extensive assistance of two staff to meet her basic needs of personal hygiene and dressing and limited assistance of two staff for bathing. [...]

Inspectors wroteBased on observation, record review and interview, 1 of 1 residents reviewed for limited range of motion did not receive the necessary care and service to prevent further decline in range of motion. R19 was admitted [DATE]. R19 has limitation of his lower extremity range of motion and has not received range of motion services since the program was initiated by therapy department. This is evidenced by: Surveyor reviewed R19's medical record and noted he was admitted [DATE] with a primary diagnosis of non Alzheimer's dementia R19's most recent minimum data set (MDS) which was a quarterly dated: 1/16/23 notes R19 rarely understands, is rarely understood and has severe cognitive impairment. R19 requires extensive assist of 2 staff for bed mobility, toilet use and hygiene. R19 is dependent on 2 staff for transfer. R19 has limited range of motion of both lower extremities. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility did not ensure staff performed proper hand hygiene for 3 of 6 residents (R) observed in the dining room. R11, R4 and R5. On 4/16/23 at 1200 PM, Certified Nursing Assistant (CNA) P did not perform appropriate hand hygiene when moving from resident to resident (R4, R5, R11) in the dining room. This is evidenced by: On 4/18/23, Surveyor reviewed the facility policy titled; Hand Hygiene. Under number 6 it states: Additional considerations; a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. On the facility Hand Hygiene Table it notes that hands should be washed with soap and water or with hand sanitizer between resident contacts. [...]