Wi Veterans Home Moses Hall

Inspectors wroteBased on interview and record review, the facility did not ensure the member environment was as free of accident hazards as possible when staff did not follow an intervention to prevent/reduce the impact of a fall for 1 member (M) (M121) of 6 sampled members. M121 had a history of falls. On 5/15/26, staff did not follow an intervention in M121's care plan to prevent recurrence when they did not lock M121's bed height adjustment with the bed in the lowest position. M121 fell out of bed, landed on their face, and required sutures in the left eyebrow. (This is being cited at past non-compliance.)

Inspectors wroteBased on interview and record review, the facility did not ensure bowel management protocol was followed for 1 member (M) (M82) of 6 members reviewed for hospitalization in a total sample of 36 members. M82 did not receive as needed (PRN) bowel medication per facility protocol. On 5/18/26, M82 was transferred to the hospital for a small bowel obstruction. In addition, M82's care plan was not updated after the hospitalization.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services during a choking incident for 1 member (M) (M1) of 1 sampled member. M1 had diagnoses including anoxic brain damage and dysphagia (difficulty swallowing) and was noted to be impulsive with lack of judgement. M1 and M1's family requested that M1 receive a regular texture diet for pleasure and were aware of the risks and benefits. On 2/4/26, M1 put half of a peanut butter sandwich in M1's mouth when Certified Nursing Assistant (CNA)-I stepped away to retrieve a towel. Staff noted M1 was choking but did not call 911 due to M1's Do Not Resuscitate (DNR) code status. M1 became pulseless and non-breathing and passed away due to the incident. [...]

Inspectors wroteBased on observation, staff and member interview, and record review, the facility did not ensure adaptive eating/drinking equipment was used during meal time to prevent burns for 2 Members (M2 and M6) of 3 sampled members. M2 did not receive coffee in a covered mug during supper on 3/1/26. M2 attempted to transfer the coffee from the uncovered mug to an insulated mug with a cover. The coffee spilled in M2's lap and resulted in burns to M2's bilateral thighs. (This example is being cited at a level G.)M6 did not receive coffee in a covered mug during lunch on 4/8/26.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate allegations of abuse for 1 member (M) (M3) of 1 sampled member. M3 made physical abuse allegations against staff on 12/15/25 and 1/3/26. The facility did not thoroughly investigate the allegations of abuse.

Inspectors wroteBased on staff interview and record review, the facility was not free of significant medication errors for 2 residents (R) (R54 and R170) of 11 sampled residents. R54 received five extra doses of baclofen (a medication used to treat muscle spasms) on 1/15/25 and 1/16/25 due to a transcription error. R54 experienced overdose symptoms that required emergency transport and admission to the hospital on 1/17/25. R170 was administered double the ordered dose of long-acting insulin on 3/1/25 and 3/2/25.

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 more than 4 of the 176 residents residing in the facility. Food items for resident consumption were not appropriately labeled and/or were beyond the discard date. Equipment in the main kitchen was not in clean condition and/or covered.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R118) of 35 sampled residents. On 3/17/25, R118 did not have a call light within reach.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R73) of 3 sampled residents. On 12/19/24, R73 reported that $150 was missing from R73's room. The facility did not thoroughly investigate the allegation of misappropriation.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the provision of care and treatment to prevent urinary tract infections (UTIs) for 1 resident (R) (R54) of 3 sampled residents. Staff did not provide suprapubic catheter (a tube that drains urine from the bladder through a small incision in the abdomen) site care for R54.

Inspectors wroteBased on staff and resident interview and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R147) of 2 residents reviewed for oxygen therapy. R147 did not have a physician order for oxygen therapy.

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 transmission of communicable disease and infection for 2 residents (R) (R79 and R72) of 3 sampled residents. R79 was on enhanced barrier precautions (EBP). On 3/18/25, Licensed Practical Nurse (LPN)-D did not wear a gown during catheter care for R79. R72 was on EBP. On 3/8/25, LPN-D did not wear a gown while administering medications via gastrostomy tube (G-tube) to R72.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure kitchen equipment was monitored appropriately to ensure food safety. This practice had the potential to affect all 164 residents residing in the facility. Mechanical warewashing wash, sanitization, and internal surface temperature logs were not consistently completed. Cooking and cooling temperature logs for food cooked in the oven were not consistently completed. Logs that documented parts per million (PPM) of the sanitizing solution in sanitizer buckets and sanitization levels in the 3 compartment sink were not consistently completed.

Inspectors wroteBased on resident and staff interview and record review, the facility did not ensure a comprehensive resident-centered care plan was developed for 1 Resident (R) (R118) of 32 sampled residents. R118 expressed delusional statements. The facility did not assess for the validity of the statements or develop a comprehensive care plan with individualized interventions to address the delusional statements.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring of high-risk medications for 1 Resident (R) (R41) of 5 residents reviewed for unnecessary medications. R41's medical record did not contain monitoring documentation for adverse reactions to anticoagulant and opioid medications.

Inspectors wroteBased on staff interview and record review, the facility did not ensure pathology results were processed in a timely manner for 1 Resident (R) (R3) of 1 resident reviewed. R3 had a skin biopsy on 5/16/23. The biopsy results were received by the facility on 6/5/23. The facility did not act on or ensure R3 was updated on the biopsy results until 8/1/23.