SAINT JOHNS ON THE LAKE
Non profit - Church related
27 Beds
Independent
Data: November 2025
Trust Grade
65/100
#120 of 321 in WI
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Saint Johns on the Lake has a Trust Grade of C+, indicating it is slightly above average in quality but not without its concerns. It ranks #120 out of 321 nursing homes in Wisconsin, placing it in the top half, and #6 out of 32 in Milwaukee County, meaning it has better options locally but there are still five facilities rated higher. Unfortunately, the facility is experiencing a worsening trend, with reported issues increasing from one in 2024 to six in 2025. Staffing is a strong point, with a perfect 5/5 star rating and a turnover rate of 37%, which is better than the state average, suggesting that staff are stable and familiar with the residents. However, the facility has incurred $32,711 in fines, which is higher than 83% of Wisconsin facilities, indicating potential compliance issues. Specific incidents include a serious finding where a resident developed deep tissue injuries because the facility did not properly assess their pressure injuries, and a concern about food safety, as improperly stored food was discovered in the facility's kitchen. Additionally, the facility failed to maintain an effective infection prevention program, which could impact all residents. While there are notable strengths in staffing and overall care, families should weigh these against the concerning trends and issues reported.
- Trust Score
- C+
- In Wisconsin
- #120/321
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Wisconsin's 48% average. Typical for the industry.
- Penalties ○ Average
- $32,711 in fines. Higher than 60% of Wisconsin facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 84 minutes of Registered Nurse (RN) attention daily — more than 97% of Wisconsin nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 13 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 37%
Needs review
1 → 6 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 6 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Wisconsin average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 37%
Near Wisconsin avg (46%)
Typical for the industry
Federal Fines: $32,711
Below median ($33,413)
Moderate penalties - review what triggered them
The Ugly 13 deficiencies on record
1 actual harm
Jun 2025
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0605
(Tag F0605)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a resident who uses a psychotropic PRN (as needed) drug had an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a resident who uses a psychotropic PRN (as needed) drug had an order limited to 14 days for 1 (R6) of 5 residents reviewed for unnecessary medications.
R6 had an order for PRN Ativan with a start date of 5/17/2025 and no end date.
Findings include:
The facility policy and procedure titled, Psychotropic Medication Use and last revised 1/2025, documents, in part:
Policy Statement
Residents will not receive medications that are not clinically indicated to treat a specific condition.
Policy Interpretation and Implementation
1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .
12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record.
4. PRN orders for psychotropic medications are limited to 14 days.
1. For psychotropic medications that are NOT antipsychotic's: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.
2. For psychotropic medications that ARE antipsychotic's: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication .
R6 was admitted to the facility on [DATE] with pertinent diagnoses that include dementia (a syndrome that can be caused by a number of diseases which over time destroy nerve cells and damage the brain, typically leading to deterioration in cognitive function (i.e. the ability to process thought) beyond what might be expected from the usual consequences of biological ageing), depression (a mental health condition characterized by persistent sadness, loss of interest or pleasure in activities, and other symptoms that significantly affect daily life), and insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep).
R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/1/25, documents a Brief Interview for Mental Status score of 03 (severe cognitive impairment). R6 has an activated Power of Attorney for decision making. R6's MDS documents a patient depression questionnaire (PHQ-9) score of 01, indicating no depressive symptoms. R6's MDS documents that R6 is usually understood and usually understands others. R6 was documented as having no behaviors exhibited during the look back period.
R6's care plan documents I have the potential for having a behavior problem related to dx (diagnosis) dementia aeb (as evidenced by) inappropriately touching others, inappropriate comments to others, attempts to kiss female staff, smears feces, revision on 1/22/2024. The pertinent intervention is administer medications as ordered. Monitor/document for side effects and effectiveness, date initiated: 12/12/2023.
R6's physician order dated 5/17/25 documents Ativan Oral Tablet 0.5 MG (Lorazepam) Give 0.5 mg by mouth every 1 hours as needed for restlessness/anxiety. The Ativan had been administered to R6 in May on 5/20, 5/21, 5/26, 5/27, 5/30 and 5/31.
Surveyor noted that the PRN order date was beyond 14 days and still active.
Surveyor noted R6's medical record did not include documentation from the attending physician or the prescribing practitioner justifying the need for R6 to receive the medication beyond a 14 day timeframe.
On 06/03/25, at 12:25 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the PRN Ativan order for R6 not having a stop date. DON-B responded it was entered by a new to us nurse, the nurse needs some education. Usually, hospice has a 6-month extension they can write out for order. DON-B will look into issue and get back to Surveyor.
On 06/03/25, at 12:38 PM, DON-B stated that the Ativan order was incorrectly put in and DON-B will need to provide education on entering a stop date to that nurse. Per DON-B the order has been discontinued.
On 06/03/25, at 12:52 PM, Surveyor interviewed Register Nurse (RN) Nursing Supervisor-G and confirmed R6 would still be getting the Ativan as R6 was using it frequently PRN. Per RN Nursing Supervisor-G they had just called hospice for a reorder, R6 will not be without the order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure for 1 (R16) of 1 residents reviewed for a level 1 and level 2 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure for 1 (R16) of 1 residents reviewed for a level 1 and level 2 PASARR (Preadmission Screening and Resident Review) had the screenings completed as required.
*R16 did not have a PASARR level 1 screen completed prior to admission to the facility. A level 1 screen was completed on the day of admission. Additionally, the facility did not ensure a level 2 screen was completed based upon the results of the level 1 screen.
Findings include:
The facility policy and procedure titled admission Criteria, dated January 2025 documents: policy statement. Our facility admits only resident who's medical and nursing care needs can be met. Policy interpretation and implementation. 9. All the admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid preadmission screening and resident review process. 2. If the level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability or related disorder he or she is referred to the state PASARR representative for the level II screening process.
R16 was admitted to the facility on [DATE] and has diagnosis of Depression. R16 had a level 1 screen completed on 8/21/2024. There is no documentation found by surveyor of a level II screening following the completed level 1.
On 8/21/2024, The Facility completed a level 1 pre-admission screen and resident review (PASARR) for R16. The form titled: Pre-admission Screen and Resident Review (PASARR) Level 1 Screen Summary, dated 8/21/2024, documents in part: Does the person have a major mental disorder? YES. Has this person received psychotropic medications to treat symptoms or behaviors of a major mental disorder? Yes. Surveyor noted, the box checked Yes for both questions. Surveyor noted in Section titled: screening result which documents, resident is suspected of having a serious mental illness. Provider response: AGREE
On 6/2/2025, at 1:46 PM, Surveyor requested the Level 2 PASARR from Director of Nursing (DON)-B as the PASARR was not observed in R16's electronic record.
On 6/2/2025, at 1:59 PM, Surveyor was informed by DON-B that the level 2 was not completed, that the level 1 was just sent out to the agency that completes the level 2. This was an oversight on our behalf. DON-B stated this was just sent out by us, it should have been completed 30 days after the level one.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility did not include 1 (R15) of 2 residents reviewed for antibiotic stewardship on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility did not include 1 (R15) of 2 residents reviewed for antibiotic stewardship on the facility line listing to ensure antibiotic use was monitored per facility protocols and ensure the antibiotic administration was included as part of the overall facility infection prevention and control program.
*R15 was receiving an intravenous (IV) Antibiotic (ABT) and was not added to the antibiotic/infection control line list. The line list is part of the antibiotic stewardship program which allows the facility to monitor and track antibiotic use and infections.
Findings include:
The facility policy and procedure titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated January 2025 documents: Policy. Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. Implementation: .
4. All resident antibiotic regimens will be documented on the facility approved antibiotic surveillance tracking form. The information gathered will include:
A. Resident name and medical record number;
B. Unit and room number;
C. Date symptoms appeared;
D. Name of antibiotic.
R15 was admitted to the facility on [DATE] with diagnosis of atrial fibrillation, dementia.
Surveyor reviewed R15's discharge paperwork from the hospital dated: 4/2/2025 which documented, IV antibiotic orders for discharge: diagnosis: right wrist presumptive septic arthritis, no culture able to be obtained. Prescription: Ceftriaxone 2 grams, IV daily duration 2 weeks. The discharge diagnoses documented as sepsis without acute organ dysfunction, due to unspecified organism.
Surveyor reviewed R15's medication administration record (MAR) from April 2025. The order for Ceftriaxone Sodium 2 grams, IV infusion to administer over 10 minutes, was documented as administered on 4/3/2025 through 4/13/2025.
On 6/03/2025, at 12:54 PM, Surveyor interviewed Infection Preventionist- D, who stated that all residents receiving antibiotics will be added to the line list for the antibiotic stewardship program. Infection Preventionist- D stated, even if the resident's antibiotic was started at the hospital, they are still added to the facility line list.
On 6/03/2025, at 1:11 PM, Surveyor and Infection Preventionist- D both reviewed the antibiotic stewardship binder for the month of April 2025. Surveyor noted R15 was not on the line list. Infection Preventionist- D stated R15 should have been added to the antibiotic stewardship program and most likely R15 wasn't added because she was presumptive (The administration of antibiotics when an infection is suspected but not yet confirmed.) for use. Infection Preventionist- D indicated even if presumptive, R15 still should have been added to the list for the antibiotic stewardship program.
On 6/3/2025, at 2:00 PM, Surveyor informed Director of Nursing (DON)-B, of the concern with R15 not being added to the line list of the antibiotic stewardship program.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 20 residents...
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Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 20 residents that eat food prepared by the facility.
*In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler. Open food was observed in the refrigerator in the resident floor main kitchen with no open or use by date.
Findings include:
The facility policy and procedure titled Food Storage, dated 5/29/2025 documents: Policy, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free of contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination.
14. Refrigerated food storage: . All foods should be covered, labeled and dated. All foods will be checked to assure that foods left quotation mark including leftovers) patient [NAME] will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
15. Frozen foods: . All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.
Food Storage Observations:
On 5/29/2025, at 9:11 AM, Surveyor observed dinner rolls in the kitchen walk in freezer, not labeled or dated with an open or use by date. Surveyor observed the dinner roll package torn open on one side and wrapped with saran wrap, Surveyor informed Director of Dining-H of the concern. Director of Dining-H also observed that the package was open, and not dated. Director of Dining-H stated that the food is supposed to be dated after opening. Director of Dining-H pulled food from the freezer and asked staff to place a date on the dinner rolls.
On 6/2/2025, at 7:57 AM, Surveyor observed sausage in the kitchen walk in freezer, not labeled or dated with an open or use by date. Surveyor observed the sausage package torn open on one side and wrapped with saran wrap, Surveyor informed Director of Dining-H, who observed that the package was open, and stated that the food is supposed to be dated after opening. Director of Dining-H pulled the sausage from the freezer and said it was supposed to be dated.
On 6/2/2025, at 11:44 AM, Surveyor made observations of the resident's (main floor) refrigerator that was in the kitchenette located in the main dining area. Surveyor observed yogurt containers in the refrigerator that were not labeled or dated. Surveyor interviewed Kitchen Director-C, who stated that the yogurts will be getting tossed out and Kitchen Director-C stated that the dates may have been rubbed off. Director of Dining-H stated that the facility will now be labeling the dates on all yogurts, so this does not happen again.
On 06/3/2025, at 03:02 PM, Surveyor informed Director of Nursing (DON)-B, of the concerns with the food storage including items in the refrigerator and freezer not having dates on them.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe enviro...
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Based on interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 21 residents in the facility.
*The facility's Water Management Plan (WMP) was not based on current standards of practice and did not:
- Include the infection preventionist as part of the water management plan committee.
- Identify corrective actions when control limits do not meet acceptable ranges of control limits (temperature ranges).
*The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris.
Findings include:
The facility policy titled Water Management Procedures: Legionella Prevention Procedures issued 5/2024 documents:
1. Water Management Program:
a. [Facility name] has developed a water management plan (WMP) to:
i. Identify ways to minimize growth and spread waterborne pathogens.
ii. Conduct routine checks of control measures to monitor areas at risk.
iii. Take corrective action if a problem is found.
iv. Verify that a WMP is working as intended.
b. The WMP is governed and directed by the organization's Safety Committee. The Safety Committee includes administrative and maintenance personnel who are knowledgeable about the facility's water system.
On 5/29/2025, Surveyor reviewed the facility's WMP binder. Surveyor noted that the WMP/ safety committee did not list the employees that participated in the meetings. Surveyor also noted that the facility did not identify what actions are to be taken when the facility's control limits were not met according to the acceptable ranges that were documented.
On 6/3/2025, at 9:18 AM, Surveyor interviewed the Director of Facilities (DoF)-E, who was recently employed about 30 days ago, along with the Facility and Maintenance Director- F who was recently promoted to the role about 3 months ago but employed with the facility in the maintenance department for about 9 years. Surveyor asked how often the WMP committee met and who attends the meetings. Maintenance Director- F stated that there are weekly operations meetings held with maintenance and laundry and that the water is discussed at times. Maintenance Director-F stated that the safety committee also has the option to participate in those meetings. Surveyor asked what staff make up the safety committee. Maintenance Director-F stated that it is campus wide and usually consists of someone from each department. Surveyor asked if the Infection Preventionist (IP) is included in any of the WMP discussions or safety committee. Maintenance Director-F stated that the IP is not included that they are aware of. Maintenance Director-F stated that the IP is not communicated with regarding the meetings or collaborated with regarding infection prevention concerns with the water systems. Maintenance Director-F stated that that the facility is trying to get the requirements worked out. Surveyor asked what protocols are in place when the control limits (for example water temperatures) are not within the control limits. Maintenance Director-F stated they are alerted and will try to find out what the cause is. Surveyor asked if there are any protocols in place to do extra testing or stop use of water etc. Maintenance Director-F stated that administration would be contacted, but not sure if further requirements are needed. Maintenance Director-F stated that they would need to check into that and again stated they know the facility is trying to get the requirements worked out.
On 6/3/2025, at 12:47 PM, Surveyor interviewed Infection Preventionist (IP)-D who stated IP-D is not part of the WMP or anything that discusses the water risks. IP-D stated that the maintenance department is in charge of the water flushes and monitoring but not aware if there is a committee or not. Surveyor shared importance of the IP involvement with the WMP because any concerns of legionella or other water borne pathogens can affect the residents and IP should have involvement to assist in the safety of the residents with whomever is managing the WMP. IP-D stated they are aware of the importance and would love to be part of it, if the facility developed one, but currently not aware of anything. Surveyor asked if there is a process in place if the facility had a positive legionella case or other water borne pathogen concern. IP-D stated they would follow any guidance from the centers of disease control (CDC), but had no specifics at current time, just would look online.
On 6/3/2025, at 2:00 PM, Director of Nursing (DON)-B was made aware of Surveyors concerns that the WMP did not Include the infection preventionist as part of the water management committee and the facility did not identify corrective actions when control limits do not meet acceptable ranges of control limits (temperature ranges). DON-B acknowledged Surveyor's concerns.
On 6/3/2025, at 9:18 AM, Surveyor toured the basement laundry room with Director of Facilities (DoF)-E and Maintenance Director- F. Surveyor asked about the vent leading from the facility dryers to the outside of the building and how often that is checked. Maintenance Director-F stated they do not check that vent. Surveyor asked if Maintenance Director-F knew where it vented out to. Maintenance Director-F stated somewhere above and on the side. Maintenance Director-F stated that the facility has a company come in to monitor all the vents from the facility to the outside, but does not think the dryer vent is on the list for the company to inspect. Surveyor asked if it is known if there is any build up or debris around the vent. Maintenance Director-F stated no but would reach out to the company to see if that is one of the vents the company looks at.
On 6/3/2025, at 2:00 PM, Director of Nursing (DON)-B was made aware of Surveyors concerns that the facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. DON-B acknowledged Surveyor's concern.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based upon observation, interview and record review the facility did not ensure they had a system in place to ensure monitoring of and maintaining of laundry vents that extended up from the laundry ro...
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Based upon observation, interview and record review the facility did not ensure they had a system in place to ensure monitoring of and maintaining of laundry vents that extended up from the laundry room to the outside. This has the potential to effect all 21 Residents residing in the facility.
*The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris.
Findings include:
On 6/3/2025, at 9:18 AM, Surveyor toured the basement laundry room with Director of Facilities (DoF)-E and Maintenance Director- F. Surveyor asked about the vent leading from the facility dryers to the outside of the building and how often that is checked. Maintenance Director-F stated they do not check that vent. Surveyor asked if Maintenance Director-F knew where it vented out to. Maintenance Director-F stated somewhere above and on the side. Maintenance Director-F stated that the facility has a company come in to monitor all the vents from the facility to the outside, but does not think the dryer vent is on the list for the company to inspect. Surveyor asked if it is known if there is any build up or debris around the vent. Maintenance Director-F stated no but would reach out to the company to see if that is one of the vents the company looks at.
On 6/3/2025, at 2:00 PM, Director of Nursing (DON)-B was made aware of Surveyors concerns that the facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. DON-B acknowledged Surveyor's concern.
Apr 2024
1 deficiency
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to effect all 21 residents in the facility.
*The facility's Water Management Plan (WMP) was not based on current standards of practice and did not:
-Include water management team members who were knowledgeable about the facility's water system
-Describe the building's water system using text and an accurate flow diagram of the system
-Include an assessment of the facility's water system to identify all locations were Legionella could grow and spread
-Identify where control measures should be applied based on where Legionella could grow and spread
-Identify acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met
-Include a process to confirm the WMP is being implemented and is effective
*Facility staff did not follow facility infection prevention and control policies and guidance related to hand hygiene.
Findings include:
On 4/22/24, Surveyor reviewed the facility assessment. Surveyor notes there is no Water Management Plan or Procedure within the facility assessment.
On 4/23/24 at 12:10 PM, Surveyor interviewed Infection Prevention Registered Nurse (RN)-E who indicates she is not aware of an active Water Management Plan within the facility. Infection Prevention RN-E indicates she recalls a Water Management Plan at her previous position at a different facility but states she is not aware of a Water Management Plan at the current facility and suggested Surveyor speak with Director of Nursing (DON)-B or Director of Maintenance-D.
On 4/23/24 at 1:26 PM, Surveyor met with Director of Maintenance-D and DON-B to review the facility's Water Management Plan. Director of Maintenance-D indicated a facility plumber will tour the facility every 2 weeks to flush water through the drains of the unoccupied rooms. The plumber then generates a work order. Surveyor requested documentation, policy, and procedures for the facility's Water Management Plan. Director of Maintenance-D and DON-B were unable to provide plans, documentation, a policy, or a procedure for the facility's Water Management Plan. There is no documentation of control measures for the water/plumbing that has not been used within the facility. Director of Maintenance-D indicated they do not have a documentation, policy, or procedure for the facility's Water Management Plan.
On 4/23/24 at 3:00 PM, Surveyor shared concerns related to the facility not having documentation, a policy and procedure for a Water Management Plan with DON-B. Surveyor requested additional information if available. No further information was provided.
2) The facility Policy and Procedure titled Handwashing/Hand Hygiene revised/reviewed 3/2024 documents (in part) .
.This facility considers hand hygiene the primary means to prevent the spread of infections.
1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.
2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.
3. Hand hygiene products and supplies (sinks, soaps, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies.
6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:
a. When hands are visibly soiled; and
b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.
7. Use an alcohol-based rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .
b. Before and after direct contact with residents;
c. Before preparing or handling medications; .
i. After contact with a resident's intact skin;
j. After contact with blood or bodily fluids; .
l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.
m. After removing gloves
8. Hand hygiene is the final step after removing and disposing of personal protective equipment.
9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routing hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
On 4/23/24, at 7:57 AM, Surveyor observed Registered Nurse (RN)-C prepare medications for R2. Medications prepared included Olopatadine Hydrochloride 0.1% eye drops. The remaining medication tablets were placed in a medication cup. RN-C also poured liquid Prosource supplement into a medication cup for R2.
On 4/23/24, at 8:02 AM, Surveyor observed RN-C don gloves and administer the medication tablets to R2 a few at a time, on a spoon, with applesauce followed by water. After administering the tablets, RN-C removed her gloves, and discarded the empty cups and gloves in the garbage can. RN-C bent over and with her bare hands, adjusted the garbage bag around the rim of the can. RN-C did not wash or sanitize her hands after touching the garbage can and donned new gloves. RN-C picked up the medication cup containing Prosource liquid and administered it to R2 followed by water. RN-C obtained a tissue and wiped R2's mouth. RN-C then changed her gloves, but did not wash or sanitize her hands. RN-C picked up the Olopatadine Hydrochloride 0.1% eye drops and while holding R2's right eyelid open with one hand, administered 1 drop into her eye. RN-C then proceeded to hold R2's left eyelid open with one hand and administered 1 drop into her eye. RN-C removed her gloves, but did not wash or sanitize her hands. RN-C did not don a new pair of gloves, picked up a tissue and proceeded to wipe R2's left eye, then right eye with the tissue. RN-C sanitized her hands upon leaving the room.
On 4/23/24, at 11:36 AM, Surveyor advised RN-C of the above observation and concern regarding handwashing. RN-C stated I hear what your saying. I did change my gloves, but I didn't wash my hands in between.
On 4/23/24, at 3:06 PM, Director of Nursing (DON)-B was advised of the above observations and concern regarding handwashing. No additional information was provided.
Feb 2023
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure 1 (R11) of 2 residents reviewed for pressure inj...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure 1 (R11) of 2 residents reviewed for pressure injuries had pressure injuries assessed in accordance with current standards of practice to ensure ongoing monitoring to help progress towards improvement.
R11 developed a deep tissue injury (DTI) to both heels on 7/26/22. The weekly wound assessment had documentation with no measurements of the wound to show the weekly progression of the pressure injury. On 1/25/23, R11 was assessed by the wound physician to have unstageable pressure injuries.
Findings include:
The facility policy and procedure entitled, Pressure Injury: Prevention and Management (Risk Assessment, Skin Assessment, and Prevention and Treatment Strategies for pressure injuries) dated 7/2016 states:
POLICY - Factors which may lead to the development of pressure injuries will be assessed and measures instituted to prevent the formation of pressure injuries. Residents with pressure injuries will receive appropriate treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing.
DEFINITIONS -
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration - Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or stage 4).
PROCEDURE
#4. The Windsor Nurse will perform rounds on all residents weekly with the wound care physician.
An additional resource the facility uses for pressure injury care is Ostendorf, A.R, [NAME], A.G & [NAME], P.A (2014). Wound Care and Irrigation in Clinical Nursing Skills & Techniques, 8th Edition. (pp. 920-941). St. Louis, MO: Elsevier Mosby.
It states: Performing A Wound Assessment
#10 (b) (1) Assess anatomic location of wound.
(2) Assess wound dimensions: Measure size of wound (including length, width, and depth) using a centimeter measuring guide.
R11 was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes, chronic kidney disease with heart failure, and obesity.
The admission Minimum Data Set (MDS) dated [DATE] documents R11 entered the facility with no unhealed pressure injuries/ulcers. The Quarterly MDS dated [DATE], documents R11's Brief Interview for Mental Status (BIMS) score of 14 indicating R11 is cognitively intact. Section G documents bed mobility, transfers, and toilet use as extensive assist, 2 + person physical assist. Section M documents R11 is at risk for pressure ulcers/injuries and has a current unhealed pressure ulcer/injury. The number of unstageable pressure ulcers due to coverage of wound bed by slough and or eschar is documented as 1. The MDS does not indicate any deep tissue injuries or other pressure injuries. The MDS does not indicate R11 refused cares.
On 2/15/23 at 10:23 AM, Surveyor interviewed R11 in her bedroom. R11 informed Surveyor that there were two pressure injuries on both of her feet and that staff puts a medication and cream on them. R11 stated that she just started to be seen by a wound doctor. R11 stated that she uses boots on her feet and pillows under her heels. Surveyor asked R11 if she could see her feet and treatment and R11 told Surveyor no, however R11 did let Surveyor lift the covers and see that she was wearing the EZ boots.
R11's Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk High for Pressure Ulcers Care Plan, initiated 9/5/21 has the following interventions:
- Educate resident/Representative about proper skin care to prevent skin breakdown, date initiated 9/5/21.
- Float heels when in bed on pillows, date initiated 1/12/22.
R11's Pressure ulcer or potential for pressure ulcer development because of immobility Care Plan, initiated 7/26/22 and DTI to bilateral heels Care Plan initiated 7/26/22 has the following interventions:
- Administer treatments as ordered and monitor for effectiveness, date initiated 7/26/22.
- Assess, record, and monitor wound healing with each dressing change. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress, date initiated 7/26/22.
- Weekly treatment documentation is to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, date initiated 7/26/22.
- Provide education to me and my family on some of the causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, date initiated 7/26/22.
- If (R11) refuses treatment, confer with (R11), the IDT, and family to determine why and try alternative methods to gain compliance, date initiated 7/26/22.
- Float heels in EZ boots at all times, date initiated 10/25/22.
- Float heels when in bed on pillows, date initiated 11/25/22.
R11's current Physician Orders documents, Record wound measurements weekly and record one time a day every Wednesday, date ordered 2/6/23. Betadine swab to bilateral heels daily in the morning for unstageable wound, start date 2/2/23. Limit sitting to 60 minutes, off load wound, every shift, start date 1/26/23. EZ boot to be worn in bed and chair to off load wound, every shift, start date 1/27/23. Float heels on pillows every shift, start date 9/22/21.
R11's discontinued Physician Orders document, Apply skin prep to heels bilaterally BID until healed for DTI, two times a day for DTI, start date 9/28/22 and discontinued 12/6/22. Record wound measurements every Monday and record one time a day every Monday, date ordered 11/1/22 and discontinued 2/6/23. Betadine swab to bilateral heels BID every morning and at bedtime for DTI, start date 12/9/22 and discontinued 1/26/23. Apply skin prep to left heel daily in the morning, start date 1/27/23 and discontinued 2/1/23. Betadine swab to right heel daily in the morning for unstageable wound, start date 1/27/23 and discontinued 2/1/23.
Surveyor reviewed R11's Weekly Skin Observation Tool forms from September 30, 2022 to February 15, 2023.
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Skin Observation Tool, dated 9/30/22, is left blank under site, type, and measurement of wound. The notes section documents, Mild discoloration to bilateral heels.
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Skin Observation Tool, dated 10/4/22, documents right heel suspected deep tissue injury measuring 1 cm (centimeters) x 0.5 cm and left heel suspected deep tissue injury measuring 2 cm x 1.5 cm.
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Skin Observation Tool, dated 10/11/22, documents right heel DTI measuring 0.5 cm x 1 cm and left heel DTI measuring 1.5 cm x 1 cm.
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Skin Observation Tool, dated 10/20/22, is left blank under site, type, and measurement of wound. The notes section documents, Mild DTI to bilateral heels.
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Skin Observation Tool, dated 10/25/22, documents right heel DTI measuring 1 cm x 1.2 cm x 0 cm and left heel DTI measuring 2 cm x 1 cm.
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Skin Observation Tool, dated 11/1/22, is left blank under site, type, and measurement of wound. The notes section documents, Right heel DTI is resolved. Mild discoloration to left heel. Skin prep applied to both heels.
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Skin Observation Tool, dated 11/7/22, is left blank under site, type, and measurement of wound. The notes section documents, Res (resident) continues to have treatment in place to bilateral heels, had small scab on lt (left) heel. Surveyor noted a DTI would not include a description of a scab.
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Skin Observation Tool, dated 11/22/22, documents right heel as a DTI measuring 3.5 cm x 4 cm and left heel as a blister 3.8 cm x 4.5 cm. The notes section is blank.
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Skin Observation Tool, dated 11/29/22, documents left heel pressure and right heel pressure. Measurement section is left blank. Documented in the notes section is, Left heel blister remain intact. DTI to the right heel.
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Skin Observation Tool, dated 12/6/22, documents left heel pressure and right heel pressure. Measurement section is left blank. Documented in the notes section is, DTI to bilateral heels. Both appear black in color and necrotic. Betadine applied.
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Skin Observation Tool, dated 12/12/22, documents right heel as suspected deep tissue injury measuring 3 cm x 4 cm x 0 cm and left heel as suspected deep tissue injury measuring 4.3 cm x 5.0 cm. The notes section does not document anything regarding the characteristics of the pressure injuries.
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Skin Observation Tool, dated 12/13/22, documents right heel pressure and left heel pressure. Measurement section is left blank. Documentation in the notes section is, DTI bilateral heels.
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Skin Observation Tool, dated 12/20/22, is left blank under site, type, and measurement of wound. The notes section documents, DTI's resolving slowly to bilateral heels. Treatment done as ordered. No complaints of pain. Heels floated on pillows.
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Skin Observation Tool, dated 12/23/22, is left blank under site, type, and measurement of wound. The notes section documents, DTI to right heel. Left heel resolved DTI.
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Skin Observation Tool, dated 12/28/22, is left blank under site, type, and measurement of wound. The notes section documents, Resolving DTI to left heel. DTI to right heel. Heels floated on pillows.
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Skin Observation Tool, dated 1/3/23, is left blank under site, type, and measurement of wound. The notes section documents, Bilateral heel DTI's. Treatment applied as ordered. Heels floated on pillows.
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Skin Observation Tool, dated 1/10/23, is left blank under site, type, and measurement of wound. The notes section documents, DTI to bilateral heels. Betadine swab applied as ordered. Resident noncompliant with treatment and cares.
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Skin Observation Tool, dated 1/17/23, is left blank under site, type, and measurement of wound. The notes section documents, DTI to bilateral heels.
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Skin Observation Tool, dated 1/23/23, documents right heel suspected DTI measuring 1 cm x 1 cm x 0 cm and left heel suspected DTI measuring 0.8 cm x 0.8 cm x 0 cm. The notes section is left blank.
Surveyor noted the above weekly wound observation tools do not consistently assess R11's pressure injuries to include characteristics of the wound bed including percentage of tissue, presence of drainage, and correct stage. The facility continued to document a deep tissue injury despite the wound deteriorating and/or opening up and notations of a scab.
On 1/25/23, a Wound Physician conducted an initial wound evaluation. The summary documents an unstageable (due to necrosis) to the right heel full thickness pressure injury measuring 0.8 cm x 0.8 cm x not measurable with 100% eschar. Recommendations include: Betadine apply once daily for 30 days, float heels in bed, off load wound, EZ boots to be worn in bed and chair to off-load wound. It also documents an unstageable DTI of the left heel partial thickness measuring 0.6 cm x 0.6 cm x not measurable with no exudate. Recommendations include: skin prep apply once daily for 30 days, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound.
The Wound Physician conducted an assessment on 2/1/23, which documents an unstageable (due to necrosis) of the right heel full thickness measuring 1.0 cm x 0.3 cm x not measurable with 100% thick adherent black necrotic tissue. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: improved. It also documents an unstageable DTI of the left heel partial thickness measuring 0.6 cm x 0.6 cm x not measurable. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: no change.
The Wound Physician conducted an assessment on 2/8/23, which documents an unstageable (due to necrosis) of the right heel full thickness measuring 1.0 cm x 0.5 cm x not measurable with 100% thick adherent black necrotic tissue. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: no change. It also documents an unstageable DTI of the left heel resolved on 2/8/23.
The Wound Physician conducted an assessment on 2/15/23, which documents an unstageable (due to necrosis) of the right heel full thickness measuring 1.0 cm x 0.5 cm x not measurable with 100% thick adherent black necrotic tissue. Recommendations include: betadine once daily, float heels in bed, off-load wound, EZ boots to be worn in bed and chair to off-load wound. Wound progress: no change.
On 2/15/23, at 2:39 PM, Surveyor reviewed R11's Progress Notes.
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Progress Note dated 1/25/23 documents, Resident's wounds evaluated and assessed by wound care MD. NNO (no new order). Continue with plan of care.
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Progress Note dated 2/1/23 documents, Seen by wound care MD, (name of doctor). heel wounds assessed and evaluated. Progressing slowly with current plan of care.
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Progress Note dated 2/8/23 documents, Seen by wound care MD, (name of doctor).heel wounds assessed and re-evaluated. Left heel DTI epithelialized and resolved. TX discontinued to left heel. Will continue to float heels with EZ boots. Right heel has 100% eschar. Wound remains dry. No noted drainage. Resident remains noncompliant with offloading and repositioning. Risk and benefits explained r/t immobility, incontinence, and diabetes. Resident verbalized understanding well.
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Progress Note dated 2/15/23 documents, Seen by wound care MD, (name of doctor) . right heel pressure wound assessed and evaluated. NNO. Continue with present plan of care.
Surveyor noted upon review of R11's progress notes there is occasional reference to R11 refusing to wear boots or refusal of care. Surveyor noted the documentation does not consistently indicate if family or the IDT was conferred with to discuss refusals. Surveyor noted the facility does not monitor the actual frequency of refusals by R11.
On 2/21/23 at 9:16 AM, Surveyor reviewed R11's Skin Observation Tool forms with Director of Nursing (DON)-B. Surveyor shared concerns that on numerous forms the wounds had no measurements documented on the weekly skin observation form after the initial assessment of bilateral DTI to R11's heels. DON-B informed Surveyor that R11's heels were being assessed weekly and that the wound was slowly healing even though R11 was resistive to treatments at times. DON-B told Surveyor that the DTIs to the heels would at times heal and then a week later they would reoccur. Surveyor asked DON-B what the expectations are for wound care and DON-B explained that nurses are documenting in the Skin Assessment in the medical record and notifying the physician of progress. DON-B stated that they did just start employing the use of a wound doctor which started at the end of January. The DON further explained that the Registered Nurse (RN) does the weekly assessment, and the (Licensed Practical Nurses) LPNs are doing the treatments. DON-B informed Surveyor that it is expected that the RN is documenting the wound measurement once a week, this would include determining if there is discharge, what that wound bed looks like, and determining if the treatment is working or not working. DON-B told Surveyor that she would have to ask where the measurements are since they should have been on the weekly skin observation tool. Surveyor asked DON-B who is responsible to ensure documentation of wounds is occurring accurately and DON-B stated that the quality assurance department will do occasional chart auditing and will alert her if there is documentation that is missing or if a nurse needs some counseling if they are found to be documenting inaccurately. Surveyor requested the facility policy and procedures for wound care.
On 2/21/23 at 10:22 AM, DON-C came to Surveyor and stated that clearly, we were not measuring wounds weekly. DON-C informed Surveyor that they were aware of the problem and started to make some changes earlier this year. DON-C stated that they did education on assessment and measuring with nurses and started having wound physicians coming into the facility weekly to do the assessments. She stated this started at the end of January 2023. DON-C stated that nurses are going through a 6-week self-paced class. She was unaware of what nurses completed this program already.
On 2/21/23 at 11:41 AM, Surveyor spoke with DON-B. She explained that she does not have an updated policy on wound care at this time which, is why we are having the current problem we are in right now. DON-B showed Surveyor a policy the facility uses which references the clinical standard of practice that they follow which is in the textbook of [NAME] and [NAME], 2014. Surveyor stated that there still must be a current policy and procedure if the policy has not been updated yet. DON-B stated she would continue to look for something.
On 2/21/23 at 12:01 PM, Surveyor requested a wound care policy and procedure from DON-C. DON-C explained to Surveyor that they are currently updating their policy and procedures and have not yet updated wound care. DON-C informed Surveyor that they are currently just following the clinical standards of practice outlined in the textbook [NAME] and [NAME], 2014. DON-C stated she would continue to look for an up to date policy and procedure.
On 2/21/23 at 12:24 PM, Surveyor informed Nursing Home Administrator-A of concerns regarding R11's DTI to the heels and the lack of weekly documentation of measurement and wound description. Surveyor also informed NHA-A of the concern regarding the lack of a facility policy and procedure for wound care and staff not being able to access it. NHA-A informed Surveyor that they are doing some changes and upgrades to policies at this time, but they should still have something to refer to. NHA-A stated he would look into this.
On 2/21/23 at 12:44 PM, DON-C spoke with Surveyor. She explained that they noticed some areas of improvement and are in the process of redeveloping many of their policies and procedures. DON-C provided a policy entitled, Clinical Nursing Skills: Wound Care. She informed Surveyor that this is the clinical standard of practice followed by Skilled Nursing Facility Wound Care. DON-C stated that nursing staff are currently going through the curriculum and several nurses have obtained their certificate. DON-C stated that policy development is reviewed at QAPI and that the Medical Director sits in on that meeting and is part of policy development and approval of new policy and procedures.
On 2/21/23 at 1:30 PM, the facility was able to provide Surveyor with a policy and procedure for wound care.
No additional information was provided at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 2 (R6 and R10) residents reviewed for weights.
R6 did not have monthly weights done as ordered.
R10 did not have weekly weights done as ordered.
Findings include:
The facility policy titled Clinical Nursing Skills: Weight revised 4/11/11 documents (in part) .
.Policy: Residents' weight will remain stable within 3% (percent) of baseline.
Purpose: To identify, monitor and implement a plan of care for residents who may be at nutritional risk.
Procedure:
1. Resident's weights will be obtained and recorded as follows:
- upon admission: Weigh for 4 consecutive weeks to obtain a baseline.
- Upon readmission: Weight for 4 consecutive weeks to obtain a baseline.
- Upon significant weight loss: Weigh 4 consecutive weeks or until back to baseline.
4. Resident Assistants (RA) will weigh residents according to the RA care card and document the weights on the weekly/monthly weight work sheet. The RA will report the residents weight to the Person First Nurse Specialist (PFNS)/designee before the end of the shift.
6. The dietetic technician will review all resident weekly/monthly weights and calculate the % of weight change from the previous weight. If the weight is plus or minus a 3% change, the dietetic technician will notify the PFNS/designee in writing on the Dietary Communication form with any recommendations.
7. The PFNS/designee will document this information in the medical record, update the nursing care plan, notify the physician, POA-HC (Power of Attorney for Health Care) or guardian as needed and inform the neighborhood team and implement daily I&O (intake and output).
8. If a weight gain or loss of 5% in 30 day period, 7.5% in a 3 month period, or 10% in a 6 month period is noted, the dietetic technician will notify the PFNS/designee in writing on a Dietary Communication form with recommendations.
9. The PFNS/designee will document the change in the nurses notes, assess the resident, consult with the Registered Dietician (RD) and notify the physician, POA-HC, or guardian of the significant gain or loss; and whether or not the resident is at risk for dehydration. The PFNS/designee will implement medical orders form the physician.
13. The PFNS/designee, RD and Dietetic technician will meet at minimum twice per month to:
- review significant weight changes.
- identify residents with significant weight loss/gain and place on I&O
1.) R10 admitted to the facility on [DATE] and has diagnoses that include Left Femur fracture, Parkinson's Disease, Orthostatic Hypotension, Alzheimer's Disease, Chronic Kidney Disease stage 3 and Hypertension.
On 2/15/23 at 10:19 AM, during initial pool, Surveyor noted R10 had a BIMS (Brief Interview for Mental Status) score of 5, indicating cognitive impairment/not interviewable. Surveyor spoke with R10's spouse who reported R10 admitted to the facility following a fall with hip fracture. She reported R10 had to go back to the hospital to drain 30 liters of fluid from his heart and lungs.
Review of facility progress notes documented:
1/3/2023 2:22 PM (physician) called regarding residents recent BNP (B-Type Natriuretic Peptide) lab results. BNP levels are elevated, MD (Medical Doctor) recommended resident be seen by cardiologist. Writer informed family who stated resident has seen (named physician) for cardiology in the past. (scheduler) notified to schedule an appointment for resident to be seen by (cardiologist).
1/5/2023 at 2:26 PM RN (Registered Nurse) assessed resident lungs and noted crackles mid lung bilaterally, use of accessory muscles, audible inspiratory wheeze, and A&O (alert and oriented) x1. RN discussed with (another) RN. RN stated she had phoned (medical doctor) to notify and was waiting for a call back. (Medical Doctor) called back and discussed resident condition, labs, potential order for chest x-ray. After discussion (Medical Doctor) determined that this was a change in condition that needed to be evaluated further in the ER (emergency room). Family requested to go to (hospital) where cardio medical doctor is located.
1/5/2023 at 3:00 PM Resident was observed using accessory muscles to breath. Inspiratory wheezing heard. SOB (short of breath). Crackles upon auscultation. POX (pulse oximetry) was 85% RA (room air). POX 95% on 3L (liters) via NC (nasal cannula). A/O x1 abnormal to baseline. Bowel sounds audible x 4 quadrants. Denies pain. C/o (complaint of) minor discomfort. Change in condition warranted resident being sent out to ER for further evaluation and treatment. MD aware and consulted on decision via phone. Bell ambulance called for transportation. Family accompanied him to hospital.
1/5/2023 at 11:13 PM Called (hospital) for resident update. Resident is admitted overnight with diagnosis of hypoxia and CHF (Congestive Heart Failure).
R10's physician orders documented: admission weight x 1 every shift for 1 Day until finished. admission weight x 1 start date 11/17/2022. admission Weight x 4 weeks one time a day every Thursday for 4 weeks start date 11/24/2022.
Surveyor review of R10's weights revealed a weight entered on 11/21/22 of 100.0 which was crossed out. Surveyor noted no other weights recorded until 1/3/23 of 166.8. R10's current weight on 2/19/23 was 164.2
Surveyor review of R10's November discharge summary and hospital records revealed no diagnosis of previous CHF. The hospital records included no documentation R10's weight, thus Surveyor was not able to confirm a weight change/gain occurred from admission to the facility to 1/3/23.
R10's hospital discharge summary documented: Acute HF (Heart Failure) EF (ejection fraction) resolved. Acute hypoxic respiratory failure due to above-resolved. There was no documentation regarding any amount of fluid removed from heart/lungs as residents' spouse reported. R10's readmission orders included an order for daily weights. Call MD if 3 lbs (pounds) weight gain in 1 day or 5 lbs weight gain in 1 week in the morning. Surveyor noted documentation reveals R10's daily weight is consistently completed along with lung assessments and MD notification.
On 2/15/23 at 11:44 AM Surveyor spoke with Director of Nursing (DON)-B regarding R10's weights. DON-B reported the weight entered in November was entered incorrectly, crossed out and another one was not entered. Surveyor confirmed with DON-B that R10's first weight entered was on 1/3/23. Surveyor asked if R10 was not weighed after admission to the facility until 1/3/23. DON-B stated: I don't think so, but he was combative.
Surveyor located no evidence or documentation R10's weight was not obtained due to refusal or R10 being combative with staff.
On 2/20/23 at approximately 3:00 PM Nursing Home Administrator (NHA)-A and Director of Nursing
(DON)-B were advised of concern R10 was not weighed weekly as ordered. No additional information was provided.
2.) R6 was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease), hypertensive heart disease and myelodysplastic syndrome.
The quarterly MDS (minimum data set) dated 12/13/22 indicates R6 is cognitively intact and needs supervision with eating.
Surveyor reviewed R6 weights since admission. On 9/7/22 R6 weighed 131.6 lbs and another weight was not obtained until 1/2/23, which was 123 lbs. Then on 2/1/23 R6 weighed at 120 lbs.
The 12/12/22 nutritional note indicates (R6) reports no recent barriers to intake, notes increased intake as she no longer has to prepare her own meals (prior to coming to (name of unit), notes inability to cook for self, weight loss). Resident declines Boost this visit, notes goal of increased intake of food. Continue to offer general diet with thin liquids, honor food preferences. Goal is to maintain body weight within 5% of CBW. Will continue to monitor tolerance of diet, weight status.
On 2/21/23 at 8:00 a.m. Surveyor interviewed DON B regarding R6 weights. Surveyor asked DON B what is the expectation regarding weighing residents. DON B stated residents should be weighed monthly at the beginning of every month. Surveyor explained to DON B R6 was not weighed in October, November and December 2022. Surveyor asked DON B, who is responsible for monitoring resident weights and DON B stated the dietician is responsible. DON B stated the current dietician started in December 2022. Surveyor explained to DON B the concern weights were not obtained for R6 for 3 months and during that time R6 had weight loss. DON B reiterated she is not responsible monitoring resident weights.
On 2/21/23 at 9:00 a.m. Surveyor interviewed RD (registered dietician) D. RD D stated she started working at the facility on 11/28/22. RD D stated she runs a monthly weight report to look for signs of any significant weight loss. RD D stated the CNAs weigh all residents a week before she runs the monthly report. RD D stated if there are missing weights she will go to the nurse or CNA and ask for the resident to be weighed. RD D stated R6 did not have a significant weight loss, which is why there are no interventions in place to prevent weight loss. RD D stated right now she is just monitoring R6 weights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility policy and procedure titled Antibiotic Stewardship dated 7/2016 documents (in part) .
. Policy: (facility) rec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) The facility policy and procedure titled Antibiotic Stewardship dated 7/2016 documents (in part) .
. Policy: (facility) recommends the judicious use of antimicrobial and antibiotic agents to promote optimal clinical outcomes and prevent the development of pathogenic organisms and the emergence of resistance.
Procedure:
1. McGeer's criteria will be used to guide physicians and staff to determine if resident symptoms meet the criteria for antibiotic treatment.
2. Basic premises: Residents will not be treated with antibiotics on the basis of a culture result if there are not clinical signs or symptoms supporting an infection.
4. If the nurse receiving the antibiotic order questions the appropriateness of the medication ordered, the Infection Preventionist (IP), RN (Registered Nurse) care manager/supervisor or Director of Nursing (DON) should be called to review the order.
5. If the antibiotic is inappropriate and the physician still wants the resident to have the antibiotic, the nurse will document in the medical record:
- MD is aware that resident symptoms do not meet McGeer's criteria.
- MD wishes to continue current antibiotic treatment.
7. The IP will routinely review all antibiotic orders. The DON and the pharmacist will be consulted as needed.
8. If necessary the IP, DON or Nurse Care Manager will contact the ordering practitioner to discuss the order.
R10 admitted to the facility on [DATE] and has diagnoses that include Left Femur fracture, Parkinson's Disease, Orthostatic Hypotension, Alzheimer's Disease, Chronic Kidney Disease stage 3 and Hypertension.
The hospital discharge medication list included an order to continue Levofloxacin (Levaquin) 500 mg (milligrams) by mouth every day. Surveyor noted there was no diagnosis or indication for use of the Levaquin and no stop date.
R10's Medication Administration Record (MAR) documented the order for Levofloxacin 500 mg give 1 tablet by mouth one time a day for Prophylactic TX for UTI which was signed out as administered from R10's admission in November 2022, through 2/20/23 while survey was in progress.
R10 was hospitalized on [DATE] and readmitted to the facility on [DATE]. The hospital Discharge summary dated [DATE] documented an order for Levofloxacin 250 mg 1 tablet by mouth daily, do not start before 1/13/23. Start date 1/13/23, end date 2/12/23.
Surveyor noted the facility did not transcribe the new order/changed dose of Levaquin 250 mg onto R10's MAR upon readmission to the facility. In addition, the facility did not enter a stop date of 2/12/23 as ordered. R10's January and February MAR documented the previous order for Levaquin 500 mg by mouth daily, signed out as having been administered from 1/13/23 to 2/20/23 while survey was in progress.
On 2/21/23 at 8:26 AM Surveyor spoke with Infection Preventionist (IP)-H and asked for additional information regarding R10's Levaquin order. IP-H reported when R10 came back from the hospital in January, the Hospitalist discharged him on the medication for a month and said do not contact for renewal. IP-H showed surveyor the order which read: Renewal requests to authorizing provider (hospitalist) prohibited. IP-H stated: I took that to mean do not contact him for renewal of the medication. He was supposed to follow up with his urologist 2 weeks after discharge, but his family canceled the appointment, so his primary doctor continued the medication. Surveyor asked if the facility spoke to R10's primary physician to discuss why the resident was taking Levaquin. IP-H reported the facility did not call the physician. The facility sends the orders to the doctor on the first of every month, they are then signed and scanned in. IP-H stated: We took that to mean to continue the order. Surveyor showed IP-H the hospital discharge summary which documented a change in the Levaquin dosage to 250 mg and a stop date of 2/12/23, both of which were not transcribed onto the MAR. Surveyor asked why the medication was not stopped as ordered. IP-H stated: Because the primary doctor signed the monthly orders and it was on the orders, so it was continued. Surveyor asked if the facility informed R10's primary physician of the stop date ordered on the hospital discharge summary. IP-H stated: No, he may not have been aware of stop date. Surveyor advised IP-H of concern the facility did not transcribe the Levaquin order correctly, resulting in R10 receiving 500 mg instead of 250 mg as ordered. In addition, a stop date was not entered as ordered, resulting in R10 receiving Levaquin past the recommended end date. IP-H reported she understood and agrees with Surveyors' concerns. No additional information was provided.
Based on interview and record review the facility did not ensure 2 (R6 and R10) of 12 residents had physician orders transcribed correctly.
R6 was admitted to the facility on [DATE] and had an order for Tobramycin that was not transcribed correctly and then was not administered as ordered.
R10 had an order for an antibiotic that was not transcribed correctly and was given the medication past the prescribed stop date.
Findings include:
1.) R6 was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease), hypertensive heart disease and myelodysplastic syndrome.
The quarterly MDS (minimum data set) dated 12/13/22 indicates R6 is cognitively intact.
The hospital discharge list dated 8/31/22 indicates Tobramycin 300 mg (milligrams)/5 ml (milliliters) nebulizer solution, inhale 5 ml (300 mg total) every 12 hours. Inhale 5 mls via nebulizer BID f(twice daily) or 28 days then stop for 28 days and repeat the cycle.
The September 2022 MAR (medication administration record) indicates Tobramycin 300 mg/5 ml was given BID from 9/8/22 through 10/5/22. Tobramycin 300 mg/5 ml then was stopped until 10/17/22 and was given for another 28 days. The physician order indicates this medication was to stop for 28 days then begin again for 28 days. The stop days were only 11 days.
The nurses note dated 10/14/22 indicates nursing called pharmacy regarding Tobramycin. It indicates unable to find the medication at the facility. (Pharmacy) stated that Medication will be delivered on 10/17/2022. Resident made aware of above.
On 2/21/23 at 8:00 a.m. Surveyor interviewed DON B regarding R6's medication. Surveyor asked DON B in October 2022, why did the Tobramycin restart after 11 days instead of the 28 days as prescribed. DON B stated she's not sure why it was restarted after 11 days. DON B stated she thinks the order was confusing for the nurses but the medication is now being given as prescribed. Surveyor asked DON B who is the prescribing provider for the Tobramycin and she stated it was R6's pulmonologist. Surveyor asked DON B if R6's pulmonologist was notified that the order was not transcribed correctly and the Tobramycin was not given as ordered and she stated she's not sure because it wasn't documented.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure each resident's drug regimen was free from unnecessary drugs fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 (R10) residents reviewed.
R10 received Levofloxacin (antibiotic) for an excessive duration and without adequate indications for its use.
Findings include:
The facility policy and procedure titled Antibiotic Stewardship dated 7/2016 documents (in part) .
. Policy: (facility) recommends the judicious use of antimicrobial and antibiotic agents to promote optimal clinical outcomes and prevent the development of pathogenic organisms and the emergence of resistance.
Procedure:
1. McGeer's criteria will be used to guide physicians and staff to determine if resident symptoms meet the criteria for antibiotic treatment.
2. Basic premises: Residents will not be treated with antibiotics on the basis of a culture result if there are not clinical signs or symptoms supporting an infection.
4. If the nurse receiving the antibiotic order questions the appropriateness of the medication ordered, the Infection Preventionist (IP), RN (Registered Nurse) care manager/supervisor or Director of Nursing (DON) should be called to review the order.
5. If the antibiotic is inappropriate and the physician still wants the resident to have the antibiotic, the nurse will document in the medical record:
- MD is aware that resident symptoms do not meet McGeer's criteria.
- MD wishes to continue current antibiotic treatment.
7. The IP will routinely review all antibiotic orders. The DON and the pharmacist will be consulted as needed.
8. If necessary the IP, DON or Nurse Care Manager will contact the ordering practitioner to discuss the order.
R10 admitted to the facility on [DATE] and has diagnoses that include Left Femur fracture, Parkinson's Disease, Orthostatic Hypotension, Alzheimer's Disease, Chronic Kidney Disease stage 3 and Hypertension.
The hospital discharge medication list included an order to continue Levofloxacin (Levaquin) 500 mg (milligrams) by mouth every day. Surveyor noted there was no diagnosis or indication for use of the Levaquin.
R10's Active Physician's orders as of 2/20/23 document: Levofloxacin 500 mg give 1 tablet by mouth in the afternoon for prophylactic TX (treatment) for UTI (urinary tract infection).
Surveyor was unable to locate urology progress notes or any documentation indicating R10's Levaquin was for prophylactic treatment for UTI.
R10's Medication Administration Record (MAR) documented the order for Levofloxacin 500 mg give 1 tablet by mouth one time a day for Prophylactic TX for UTI which was signed out as administered from R10's admission in November 2022, through 2/20/23 while survey was in progress.
On 2/20/23 at 10:03 AM Surveyor spoke with Director of Nursing (DON)-B regarding R10's Levaquin order. DON-B reported R10 came from the hospital on the prophylactic antibiotic. She reported R10 was to follow up with urology, however due to health concerns of pneumonia then Covid, he was very weak and family did not want him going out for the appointment until he was stronger. Surveyor advised DON-B the hospital order did not include a diagnosis or indication for use as prophylactic treatment for UTI. Surveyor asked for any additional information regarding the Levaquin order and it's indication for use.
On 2/20/23 at 3:00 PM during the daily exit meeting, Surveyor advised Nursing Home Administrator (NHA)-A and DON-B of concern related to Levaquin having been administered for an extended period of time and not having clear indication for use. Surveyor advised the hospital discharge summary did not include a diagnosis or indication for use as prophylactic treatment for UTI. Surveyor asked where the addition of prophylactic treatment on the order originated. DON-B reported she thought R10 admitted on the Levaquin for that reason.
On 2/21/23 at 8:13 AM Surveyor spoke with DON-B and asked if there was any additional information regarding R10's Levaquin. DON-B reported Infection Preventionist (IP)-H was working on it and she would check.
On 2/21/23 at 8:26 AM Surveyor spoke with IP-H and asked if she can provide any additional information regarding R10's Levaquin. IP-H stated: I'm confused too. He was on it from the beginning when he admitted in November for prophylactic treatment of UTI. Surveyor asked if the facility spoke to R10's primary physician to inquire why R10 was taking the antibiotic. IP-H stated: No. We send the orders to the doctor on the 1st of every month, they sign them and they are scanned in. Surveyor confirmed the facility did not call the physician to obtain a diagnosis or indication for use of Levaquin. IP-H stated: No. No-one called him regarding the order, he just signed the orders, we took that to mean to continue the order. Surveyor advised IP-H the hospital discharge summary did not document a diagnosis for the Levaquin, nor does it document it's use as prophylactic treatment for UTI. Surveyor asked where the addition of prophylactic treatment for UTI came from. IP-H reported she did not know, but she was not a fan of prophylactic antibiotic orders.
IP-H reported the facility has a meeting every month with the medical director and they are meeting next week. IP-H stated: We'll talk about it and get it discontinued. Surveyor clarified instruction to discontinue the medication was not given by Surveyor. Surveyor reported concern is that Levaquin has been given to R10 for an extended period of time without adequate indications for it's use. IP-H reported she understood and agrees with Surveyors' concerns.
On 2/21/23 at 8:49 AM Surveyor spoke with DON-B and asked what criteria the facility uses to identify infections. DON-B asked what Surveyor meant. Surveyor provided example of McGeer's. DON-B stated: I'm not sure, I'll have to find out, I don't want to give you the wrong information.
No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the deve...
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Based on observation, interview and record review the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 3 of 3 residents (R4, R11 and R124) residing on the unit.
The glucometer, which is shared between residents, was not cleaned according to the label instructions.
Findings include:
The facility policy titled Cleaning and Disinfection of Resident Care Items and Equipment revised 6/2022 documents (in part) .
.Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to manufacturer recommendations for disinfection and the OSHA bloodborne pathogens standard.
Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).
2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.
The Sani-Cloth bleach germicidal disposable wipe label read (in part) .
.Kills HIV-1 (Aids virus), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) on environmental surfaces/objects previously soiled with blood/body fluids in one (1) minute.
Cleaning procedure: All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe.
Hospital, Healthcare and Critical Care use sites: May be used on hard nonporus surfaces of blood glucose meters.
To clean, disinfect and deodorize: Use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4 minute wet contact time.
On 2/20/23 at 7:43 AM, during medication pass observation, Surveyor observed Licensed Practical Nurse (LPN)-G prepare blood sugar testing for R4.
LPN-G gathered supplies which included a glucometer, test strip, alcohol wipe and lancet and proceeded to R4's room. LPN-G sanitized her hands, donned gloves and obtained R4's blood sugar. No concerns were identified with procedure. LPN-G removed her gloves and washed her hands. She picked up the glucometer and walked back to the medication cart (A).
LPN-G proceeded to wipe the glucometer with an alcohol wipe while saying aloud I don't know where the bleach wipes are. A second nurse standing nearby went into the medication room and returned with a container with an orange top labeled Sani Cloth bleach germicidal disposable wipe. LPN-G removed 1 wipe from the container and proceeded to wipe the glucometer for approximately 5 seconds before placing the glucometer on top of the medication cart.
Surveyor asked LPN-G if she had any more resident blood sugars to do. LPN-G reported she needed to get 2 more residents' blood sugars, but one was not awake yet and the other likes it done later.
Surveyor asked if residents have their own glucometers or if the same glucometer is used on every resident. LPN-G reported the glucometer is shared between residents.
On 2/20/23 at 8:40 AM Surveyor spoke with LPN-G and confirmed residents share the glucometer. Surveyor asked how the glucometer is cleaned. LPN-G reported she was always taught to wipe it with an alcohol wipe first, then wipe it with a bleach wipe. Surveyor asked if she knew the facility policy for cleaning the glucometer, to which she replied: No. I thought it was to use the bleach wipe. Surveyor advised LPN-G of observation wiping glucometer with the bleach wipe for 5 seconds. LPN-G reported she did not know the label instructions indicated the glucometer needed to remain visibly wet for a period of time. Surveyor advised LPN-G to read the the instructions on the label for contact time to remain wet. LPN-G reported she would read the label and clean the glucometer before proceeding to do any other blood sugars.
On 2/20/23 at 8:45 AM Surveyor spoke with Infection Preventionist (IP)-H and advised her of the concern observed regarding cleaning of the glucometer. IP-H reported she thought the residents had their own glucometers. Surveyor asked for a container of the Sani Cloth bleach wipes, facility policy and procedure for cleaning of glucometers, a list of residents that require blood sugar testing and if any of those residents have bloodborne pathogens.
Surveyor received the requested information and confirmed none of the residents that utilize the shared glucometer have bloodborne pathogens.
On 2/20/23 at approximately 3:00 PM, Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above concern regarding cleaning of the shared glucometer. No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview, the facility did not ensure staff working in the kitchen followed standards of practice for proper handling of food while maintaining hand hygiene. T...
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Based on observation, record review and interview, the facility did not ensure staff working in the kitchen followed standards of practice for proper handling of food while maintaining hand hygiene. This had the potential to effect 8 out of 23 residents who eat food prepared in the main kitchen.
Cook-F was observed donning gloves after washing her hands, Cook-F then proceeded to touch menus, contaminating her hands. Cook-F did not change gloves or rewash her hands before proceeding to prepare sandwiches for residents.
Findings include:
The facility policy, entitled Gloves, Use of bare Hand Contact with Food and Use of Plastic Gloves, dated 11/2018, states: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served.
Procedure:
#3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purposes, and discarded when damaged or soiled, or when interruptions occur in the operation.
#6. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed.
G. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.
On 2/20/23, at 12:03 PM, Surveyor observed Cook-F prepare and serve lunch from the kitchen on the unit. Cook-F was preparing turkey club sandwiches.
On 2/20/23, at 12:03 PM, Surveyor observed Cook-F wash her hands and put gloves on. Cook-F then picked up a pile of resident menus and sorted through them, [NAME] F laid the resident menus back down on the countertop and proceeded to grab four slices of bread from the bread bag with her gloved hand and walked to the toaster where she removed four slices of toast and put in the four slices of bread into the toaster. Cook-F then used a spatula to spread mayonnaise onto the 4 pieces of toasted bread. Cook-F then picked up pre-made stacks of deli turkey meat, Swiss cheese, lettuce and a tomato slice and placed it onto the toasted bread with the same gloves on her hands. She did this to all four pieces of toasted bread. Cook-F then removed the gloves and washed her hands.
Surveyor noted that Cook-F did not remove gloves and wash hands after contaminating her hands after touching resident menus, before preparing four resident turkey club sandwiches.
On 2/20/23, at 12:20 PM, Surveyor observed Cook-F pick up and sort through resident menus with gloved hands. Cook-F then removed four slices of toast from toaster with her gloved hands and placed the toast onto the countertop. She then used a spatula to spread mayonnaise onto the 4 pieces of toasted bread. Cook-F then removed the gloves and washed her hands.
Surveyor noted that Cook-F did not remove gloves and wash hands after contaminating her hands after touching resident menus, before preparing toast for resident turkey club sandwiches.
On 2/20/23, at 12:23 PM, Surveyor observed Cook-F with gloved hands pick up several resident menus and sort through them. She then set the menus down and picked up a stack of deli turkey meat with Swiss chess, lettuce and a sliced tomato with gloved hand and placed it on a plate. Cook-F then used gloved hand to reach into a large bag of potato chips and pull out a handful of chips and added them to the plate. Cook-F then proceeded to apply mayonnaise with a spatula on two slices of toasted bread and then top it with the deli turkey meat, Swiss cheese, lettuce, and sliced tomato. Cook-F plated the turkey club sandwich on the plates and removed her gloves and washed her hands.
Surveyor noted that Cook-F did not remove gloves and wash hands after contaminating her hands after touching resident menus, before preparing resident turkey club sandwiches.
On 2/20/23, at 12:54 PM, Surveyor interviewed Dietary Manager-E (DM) regarding the facility's policy on touching ready to eat food. DM-E informed Surveyor that it's their policy to wash hands and then apply gloves and that in between tasks if the gloves get dirty then they have to remove the gloves and rewash the hands and apply new gloves. Surveyor informed DM-E of earlier observations of Cook-F touching resident menus with gloved hands and then preparing bread in the toaster and making turkey club sandwiches with the same gloved hands. DM-E informed Surveyor that that is not their practice, and she should have stopped the task and removed her gloves, rewashed, and gloved up again.
On 2/20/23, at 3:10 PM, at the end of the day meeting, Surveyor informed the Nursing Home Administer-A, Director of Nursing-B and Director of Nursing-C of the observations.
No further information was provided at the time.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 37% turnover. Below Wisconsin's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 harm violation(s), $32,711 in fines, Payment denial on record. Review inspection reports carefully.
- • 13 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $32,711 in fines. Higher than 94% of Wisconsin facilities, suggesting repeated compliance issues.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Saint Johns On The Lake's CMS Rating?
CMS assigns SAINT JOHNS ON THE LAKE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Wisconsin, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Saint Johns On The Lake Staffed?
CMS rates SAINT JOHNS ON THE LAKE's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 37%, compared to the Wisconsin average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Saint Johns On The Lake?
State health inspectors documented 13 deficiencies at SAINT JOHNS ON THE LAKE during 2023 to 2025. These included: 1 that caused actual resident harm and 12 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Saint Johns On The Lake?
SAINT JOHNS ON THE LAKE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 27 certified beds and approximately 21 residents (about 78% occupancy), it is a smaller facility located in MILWAUKEE, Wisconsin.
How Does Saint Johns On The Lake Compare to Other Wisconsin Nursing Homes?
Compared to the 100 nursing homes in Wisconsin, SAINT JOHNS ON THE LAKE's overall rating (4 stars) is above the state average of 3.0, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Saint Johns On The Lake?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Saint Johns On The Lake Safe?
Based on CMS inspection data, SAINT JOHNS ON THE LAKE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Wisconsin. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Saint Johns On The Lake Stick Around?
SAINT JOHNS ON THE LAKE has a staff turnover rate of 37%, which is about average for Wisconsin nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Saint Johns On The Lake Ever Fined?
SAINT JOHNS ON THE LAKE has been fined $32,711 across 1 penalty action. This is below the Wisconsin average of $33,406. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Saint Johns On The Lake on Any Federal Watch List?
SAINT JOHNS ON THE LAKE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.