Wi Veterans Home at Chippewa Falls

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure a resident at risk of Pressure Injury (PI) development received the necessary treatment and services to prevent pressure injuries for 1 of 2 sampled residents (R) (R3).- R3 has a history of pressure injuries to their heels. Staff did not offload R3's heels with pressure-relieving devices per the plan of care.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who requires dialysis receives such service, consistent with professional standards of practice for 1 of 1 resident (R7) reviewed for dialysis. The facility failed to provide ongoing assessment of R7's condition and monitoring for complications before and after dialysis treatments. This is evidenced by:Facility's policy titled Dialysis with the revised date of 04/2026 documented, It is the policy of this community to provide coordination of care with the resident's dialysis provider. R7 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, and type 2 diabetes mellitus. R7's Minimum Data Set (MDS) assessment completed on 04/15/26 confirmed R7 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R7's care plan included: DIALYSIS: [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 72 residents sampled. (R271) The facility did not follow provider recommendations to taper gabapentin (anticonvulsant medication) and to monitor speech for R271.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received equipment to maintain or prevent further reduction in ROM for 1 of 2 residents (R) R29 reviewed. This is evidenced by: R29 was re-admitted to the facility on [DATE] with diagnoses including, in part, spinal stenosis, atrial fibrillation, osteo arthritis, peripheral venous insufficiency, polyneuropathy, hypertension, dysphagia, and localized edema. R29's Minimum Data Sheet (MDS) dated on 03/24/25 indicates that R29 is totally dependent with all cares. R29's Activities of Daily Living (ADL) care plan and Certified Nurse Assistant (CNA) [NAME] states, in part: -Dressing/Grooming: Adaptive clothing for upper body. Right hand splint and apply palm protector with foam piece to right hand in the AM. [...]

Inspectors wroteBased on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (R19) reviewed. R19 did not have fall intervention in place of leaving wheelchair at side of bed to prevent falls. This is evidenced by: The facility policy titled Accident/Falls last revised on 12/24, states: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Under section titled Procedure states in part: 10. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 1 of 7 residents (R) observed for medication administration. The facility had 25 opportunities and 9 medication errors resulting in a 36% error rate. Registered Nurse (RN) G crushed 9 different medications in applesauce and spilled a portion of the medications. RN G administered remaining medications in cup to R17. This is evidenced by: On 06/10/25 at 7:32 AM, Surveyor observed RN G prepping R17's medications. RN G placed Tylenol 325mg 2 tabs, Allopurinol 100 mg 1 tab, Depakote sprinkles 125mg 2 capsules, Donepezil 10mg 1 tab, Ziprasidone 40mg 1 tab, Losartan 25 mg 1 tab, Rexutil 2mg 1 tab, Sertraline 25 mg 2 tabs, Sertraline 100mg 1 tab, and Furosemide 20 mg 1 tab, and 10mg ½ tab into a medicine cup. RN G opened Depakote capsules and sprinkled into medicine cup. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 2 of the 17 residents (R) reviewed, R29 and R42. -Certified Nurse Assistant (CNA) J did not perform hand hygiene when providing peri cares for R29 or clean BM off R29's Broda chair. -Assistant Director of Nursing (ADON) H did not provide a protective barrier during wound dressing change for R29. -CNA J did not perform hand hygiene after providing catheter care for R42.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 2 of 6 residents reviewed (R32 and R53) for pressure injuries (PI) received necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility did not ensure 2 of 5 residents (R) reviewed for bowel and bladder incontinence (R32 and R53) received appropriate treatment and services to prevent Urinary Tract Infections (UTI). This is evidenced by: Acello, [NAME] RN MSN. The Long-Term Care Nursing Desk Reference. Chapter 13, pages 214-215 offer the following discussion on urinary incontinence in Long Term Care: . Incontinence is a medical problem that is, in many instances, beyond the resident's control. Incontinence is not a normal consequence of aging and can frequently be cured or improved . Incontinence in long-term care facilities can often be linked to the facility's staff. Over time, staff become insensitive to incontinence . the sensation of needing to use the toilet is one of the last to be lost in cognitively impaired residents. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not ensure proper hand hygiene was conducted to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections during wound care for 1 of 1 residents (R) R28. This is evidenced by: The facility policy, entitled Handwashing revised on 11/2022 states in part that alcohol-based hand sanitizer should be used after contact with blood, body fluids or contaminated surfaces .immediately after glove removal. R28 returned to facility on 02/19/2024 with a pressure ulcer on left heel following hospitalization and placed on Enhanced Barrier Precautions (EBP). R28's comprehensive care plan states: Follow facility policies/protocols for the prevention/treatment of skin breakdown. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure residents received timely pressure injury assessments, physician consult, and pressure relief interventions consistent with professional standards of practice to prevent and promote healing of pressure injuries for 1 of 3 residents (R4) reviewed for pressure injuries.