SHOREHAVEN HLTH & REHAB CTR
Non profit - Corporation
88 Beds
Independent
Data: November 2025
Trust Grade
80/100
#66 of 321 in WI
Photo by Shorehaven
Photo by Rae Ann Scherr
Photo by Shorehaven
1 / 10 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Shorehaven Health & Rehab Center has a Trust Grade of B+, which means it is above average and generally recommended. It ranks #66 out of 321 nursing homes in Wisconsin, placing it in the top half of facilities statewide, and #2 out of 17 in Waukesha County, indicating it is one of the best local options available. However, the facility is experiencing a worsening trend, with the number of issues increasing from 2 in 2024 to 3 in 2025. Staffing is a strong point, with a 5-star rating and only 31% turnover, which is significantly lower than the state average of 47%. On the downside, the facility has had some serious findings, including a failure to use a foot pedal on a wheelchair during transport, which could create a risk of accidents, and inadequate care related to pressure injuries, indicating that preventative measures were not properly implemented. It's worth noting that there have been no fines reported, which is a positive sign, but RN coverage is only average, meaning there might be less oversight compared to facilities with higher RN staffing levels. Overall, while there are commendable aspects of Shorehaven, families should consider both the strengths and the serious concerns when making a decision.
- Trust Score
- B+
- In Wisconsin
- #66/321
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 31% turnover. Near Wisconsin's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Wisconsin facilities.
- Skilled Nurses ✓ Good
- Each resident gets 73 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 ○ Average
- 8 deficiencies on record. Average for a facility this size. Mostly minor or procedural issues.
80/100
Top 20%
Needs review
2 → 3 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 3 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (31%)
17 points below Wisconsin average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 31%
15pts below Wisconsin avg (46%)
Typical for the industry
The Ugly 8 deficiencies on record
2 actual harm
Jun 2025
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 2 sampled residents received writ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 resident (R) (R9) of 2 sampled residents received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility.
Neither R9 or R9's representative were provided with a written bed hold notice that included the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility when R9 was transferred to the hospital on 6/6/25.
Findings include:
The facility's Bed Hold policy, dated 11/2016, indicates: .Before any hospital transfer or therapeutic leave, the facility will provide written information specifying: i. Duration of state bed-hold policy; ii. Reserve bed payment policy (if applicable); iii. Facility's bed-hold periods and return policies; iv. Any cost associated with bed hold beyond state limits; v. Resident's rights to appeal discharge decisions .
From 6/9/25 to 6/11/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had a diagnosis of dementia. R9's Minimum Data Set (MDS) assessment, dated 3/19/25, indicated R9 had moderate cognitive impairment. R9 had an activated Power of Attorney for Healthcare (POAHC).
R9's medical record indicated R9 was sent to the hospital for evaluation on 6/6/25. Surveyor requested a copy of the bed hold notice for R9's hospital transfer. On 6/11/25, Surveyor reviewed a Financial Consent to Bed Hold document that was signed on 3/10/22.
On 6/10/25 at 2:54 PM, Surveyor interviewed Director of Nursing (DON)-B and reviewed the facility's bed hold procedure. DON-B indicated the facility reviews the bed hold policy with residents as part of the admission packet. DON-B indicated residents sign a Financial Consent to Bed Hold form upon admission. DON-B indicated when a resident is transferred to the hospital, a bed hold letter is included in the paperwork that is sent with the resident. If a resident spends the night in the hospital, a staff member calls the resident or their representative to confirm their bed hold preference and documents the conversation in a progress note.
On 6/10/25, Surveyor reviewed the bed hold letter and noted it did not include the daily rate for the bed reserve payment. The bed hold letter also did not contain a signature line for the resident to acknowledge receipt of the bed hold policy.
On 6/11/25 at 8:38 AM, Surveyor interviewed Social Worker (SW)-L who indicated when a resident is transferred to the hospital, a bed hold notice is sent with the resident in a packet of paperwork. SW-L indicated a bed hold notice is not discussed with the resident if the resident returns from the hospital the same day. If the resident is admitted to the hospital overnight, the facility asks hospital staff to provide the bed hold notice to the resident. SW-L indicated when a resident is admitted overnight, SW-L calls the resident or their representative the following day to discuss the bed hold policy. SW-L indicated SW-L does not discuss the daily rate or appeal rights with the resident or their representative.
On 6/11/25 at 10:12 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about the bed hold procedure. NHA-A confirmed a bed hold form is signed upon admission to the facility. NHA-A indicated the bed hold letter is provided to a resident before transfer and a phone call is made the next day to discuss the bed hold with the resident or their representative. NHA-A indicated the reserve bed payment rate is discussed during the follow-up phone call.
On 6/11/25 at 10:45 AM, Surveyor interviewed Registered Nurse (RN)-M who indicated RN-M informs residents that bed hold information is available in the hospital paperwork packet. RN-M indicated the bed hold letter is not given directly to the resident or their representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R1) of 2 sampled residents.
The facility did not ensure R1's oxygen orders were consistently followed.
Findings Include:
The facility's Oxygen Administration Concentrators policy, revised 4/19/25, indicates: .Procedure: .C. Press power switch on position and adjust oxygen flow .D. Read the center of the ball with the meter at eye level. If unable to obtain the proper flow rate, check for kinks in the tubing or loose connections.
From 6/9/25 to 6/11/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease, spinal stenosis, lumbar, major depressive disorder, and unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder. R1's Minimum Data Set (MDS) assessment, dated 12/17/24, had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R1 had moderately impaired cognition. R1's most recent MDS assessment, dated 3/19/25, did not contain a BIMS score.
A care plan, dated 1/17/23 and last revised 3/26/25, indicated R1 had low oxygen readings when asleep due to sleep apnea related to a stroke and used a BiPAP machine. The care plan contained indicated R1 needed help putting on the BiPAP nasal mask with 4 liters of oxygen at bedtime. The care plan indicated R1 wore the mask throughout the night and during the day when R1 napped in bed.
R1's Treatment Administration Record (TAR) contained the following orders:
~ Oxygen at 4 liters at bed time (HS) for continuous positive airway pressure (CPAP), dated 2/1/21 to 6/10/25.
~ Oxygen at 4 liters when using BiPAP every shift, dated 6/10/25.
On 6/9/25 at 1:58 PM, Surveyor observed R1 asleep in bed. R1 used a bilevel positive airway pressure (BiPAP) machine and had an oxygen concentrator that was set at 1 liter of oxygen.
On 6/10/25 at 9:40 AM, Surveyor observed R1 asleep in bed with the BiPAP machine on, however, the oxygen concentrator was not on.
On 6/10/25 at 9:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G about R1's oxygen. LPN-G entered R1's room and turned the oxygen concentrator on. Surveyor noted the oxygen level was set at 1.5 liters which LPN-G confirmed.
On 6/10/25 at 12:02 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R1's oxygen concentrator should be set at the level ordered by the physician.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Dishwasher Temperatures:
The 2022 Wisconsin Food Code documents at 4-501.110 .Mechanical Warewashing Equipment, Wash Solution Te...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Dishwasher Temperatures:
The 2022 Wisconsin Food Code documents at 4-501.110 .Mechanical Warewashing Equipment, Wash Solution Temperature: (A) The temperature of the wash solution in spray type warewashers that use hot water to sanitize may not be less than: (1) For a stationary rack, single temperature machine, 74° C (165° F); (2) For a stationary rack, dual temperature machine, 66° C (150° F); (3) For a single tank, conveyor, dual temperature machine, 71° C (160°F); or (4) For a multitank, conveyor, multitemperature machine, 66° C (150° F).
The facility's Maintenance, Sanitation and Safety policy, revised 1/2018, indicates: .Sanitation: The Food Service Manager, with the help of the Dietitian, is responsible for the supervision and training of employees in proper sanitation within the food service department .The Food Service Manager is responsible for maintaining report files for dish machine service and taking corrective action if necessary .All resident dishes (china, cups, silverware) are washed by staff on each unit after each meal in the dishwasher. The dishwashers are checked daily to ensure they are maintaining temperatures .A warewashing procedure is developed and followed .The Food Service Manager and Dietitian are responsible for maintaining safety standards. The Director of Food Service is responsible for developing safety rules and reviewing them with all employees .
On 6/10/25 at 8:22 AM, Surveyor toured the Turnberry unit kitchen and reviewed the June 2025 Household Dishwasher Record. The form indicated the wash cycle should be 150 degrees or higher and the final rinse cycle should be 180 degrees or higher. The form contained one slot labeled AM Shift and one slot labeled PM Shift for each date in June. The June log contained one entry for a dishwasher temperature on 6/10/25. Surveyor noted all other dates did not have documentation to indicate the dishwasher temperatures were monitored.
On 6/10/25 at 8:42 AM, Surveyor toured the [NAME] unit kitchen and reviewed the June 2025 Household Dishwasher Record. The form indicated the wash cycle should be 150 degrees or higher and the final rinse cycle should be 180 degrees or higher. The form contained one slot labeled AM Shift and one slot labeled PM Shift for each date in June. The log had missing dishwasher temperatures on 6/1/25, 6/5/25, 6/6/25, and 6/9/25 and only contained documentation for either the AM or PM shift from 6/2/25 through 6/4/25 and 6/7/25 through 6/8/25.
During the unit kitchen tour, Surveyor interviewed HM-J who worked in the [NAME] and Turnberry units on the AM shift. HM-J confirmed the logs only had slots for the AM and PM shifts. HM-J indicated the dishwasher is continuously run because breakfast is cooked on the unit and dishes for all meals are washed in the unit dishwashers. HM-J indicated the logs should be filled out and previous logs are kept in the kitchen with DD-E.
On 6/10/25 at 11:13 AM, Surveyor interviewed DD-E who indicated unit dishwashers are used to wash cooking dishes, utensils, plates, cups, and anything that is used for food service on the unit. DD-E indicated Homemakers and CNAs are responsible for documenting dishwasher temperatures in the AM and PM on each unit. Surveyor noted the Turnberry unit did not have a June 2025 Household Dishwasher Record. Surveyor requested copies of the [NAME] and Turnberry dishwasher logs for May and June 2025.
On 6/11/25, Surveyor received and reviewed copies of the dishwasher logs for the [NAME] and Turnberry units. The May 2025 dishwasher log for the [NAME] unit did not contain temperature documentation for 5/8/25, 5/16/25, and 5/21/25. All other days contained either an AM or PM temperature only. The May 2025 dishwasher log for the Turnberry unit did not contain temperature documentation for 5/1/25, 5/4/25 through 5/5/25, 5/7/25 through 5/11/25, 5/15/25 through 5/17/25, 5/19/25, 5/24/25 through 5/25/25, and 5/28/25 through 5/31/25. All other days contained either an AM or PM temperature only. The June 2025 Turnberry unit dishwasher log did not contain temperature documentation for 6/2/25 through 6/8/25 and for 6/11/25 and contained either an AM or PM temperature only for 6/1/25, 6/9/25, and 6/10/25.
Cooked Food Temperatures and Hot/Cold Holding Temperatures:
The 2022 Wisconsin Food Code documents at 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding .Time/Temperature Control for Safety Food shall be maintained: (1) At 57° Celsius (C) (135° Fahrenheit (F)) or above, except that roast cooked to a temperature and for a time specified in 3-401.11 (B) or reheated as specified in 3-403.11 (E) may be held at a temperature of 54° C (130° F) or above; (2) At 5° C (41° F) or less.
The 2022 Wisconsin Food Code documents at 3-401.11 Raw Animal Foods: .(A) Except as specified under (B), (C), and (D) of this section, raw animal foods such as eggs, fish, meat, poultry, and foods containing these raw animal foods, shall be cooked to heat all parts of the food to a temperature and for a time that complies with one of the following methods based on the food that is being cooked: (1) 63° C (145° F) or above for 15 seconds for: P (a) Raw shell eggs that are broken and prepared in response to a consumer's order and for immediate service .
The 2022 Wisconsin Food Code documents at 3-501.19 Time as a Public Health Control: (A) Except as specified under (E) of this section, if time without temperature control is used as the public health control for a working supply of time/temperature control for safety food before cooking, or for ready to eat time/temperature control for safety food that is displayed or held for sale or service .(1) The food shall have an initial temperature of 5 degrees C (41 degrees F) or less when removed from cold holding temperature control, or 57 degrees C (135 degrees F) or greater when removed from hot holding temperature control .
On 6/10/25 at 8:42 AM, Surveyor toured the [NAME] unit kitchen and reviewed Meal Service Temperature Logs. Surveyor noted there were not Meal Service Temperature Logs for 6/8/25 to 6/14/25.
At that time, Surveyor interviewed HM-J who worked on the [NAME] and Turnberry units during the AM shift. HM-J indicated breakfast is cooked in each unit kitchen. HM-J indicated lunch and dinner are cooked in the main kitchen, brought to the units, and served from the [NAME] unit steam table. HM-J confirmed meal temperatures should be documented on Meal Service Temperature Logs.
On 6/10/25, Surveyor requested May and June 2025 Meal Service Temperature Logs from DD-E.
On 6/11/25, Surveyor received and reviewed Meal Service Temperature Logs provided by DD-E and noted the following:
~ From 5/425 through 5/10/25:
Breakfast on 5/4/25, 5/6/25, and 5/9/25 indicated Made to Order and did not contain temperatures.
Lunch on 5/4/25, 5/9/25, and 5/10/25 did not contain documentation of food held for service temperatures.
Supper on 5/7/25 and 5/8/25 did not contain documentation of food held for service temperatures.
~ From 5/11/25 through 5/17/25:
Breakfast on 5/11/25, 5/12/25, 5/13/25, 5/15/25, and 5/17/25 did not contain documentation of cooked food or cold food temperatures.
Lunch on 5/12/25, 5/15/25, and 5/17/25 did not contain documentation of hot/cold holding temperatures.
Supper on 5/16/25 did not contain documentation of hot/cold holding temperatures.
~ From 5/18/25 through 5/24/25:
Breakfast on 5/18/25, 5/21/25, and 5/23/25 did not contain cooked food or cold food temperatures; 5/20/25 and 5/21/25 indicated Made to Order for cooked food temperatures.
Lunch on 5/18/25, 5/19/25, and 5/23/25 did not contain documentation of hot/cold food holding temperatures.
Supper on 5/21/25 did not contain documentation of hot/cold food holding temperatures.
~ From 5/25/25 through 5/31/25:
Breakfast on 5/26/25 and 5/30/25 did not contain documentation of cooked food or cold food temperatures; 5/5/27 indicated Made to Order for cooked food temperatures.
~ From 6/1/25 through 6/7/25:
Breakfast on 6/1/25 ,6/2/25, 6/3/25, 6/5/25, and 6/7/25 did not contain documentation of cooked food or cold food temperatures.
A Meal Service Temperature Log for the week of 6/8/25 through 6/14/25 was not provided.
On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated there was no log for 6/8/25 through 6/14/25 and confirmed cooked food and hot/cold holding temperatures were not consistently documented. DD-E confirmed staff on the units who work in the kitchen are trained to take cooked food and hot/cold holding temperatures for every meal.
Refrigerator and Freezer Temperatures:
The 2022 Wisconsin Food Code documents at 3-202.11 Temperature: .Perishable food items must be stored at appropriate temperatures to prevent spoilage and reduce the risk of foodborne illnesses. Refrigerators should be set below 41° F (5° C) and freezers at or below 0° F (-18° C).
During a tour on 6/10/25 at 8:22 AM, Surveyor noted the Turnberry unit did not have a refrigerator or freezer temperature log. Surveyor also noted the [NAME] unit June 2025 refrigerator and freezer temperature log did not contain temperatures for 6/6/25 or 6/9/25.
At that time, Surveyor interviewed HM-J who indicated temperatures for the [NAME] and Turnberry unit refrigerators and freezers are documented on a log located on the refrigerator/freezer. HM-J indicated the previous months are given to DD-E for filing.
On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated refrigerator and freezer temperatures should be monitored and documented daily. Surveyor requested copies of the [NAME] and Turnberry unit refrigerator and freezer temperature logs for May and June of 2025.
On 6/11/25, Surveyor received and reviewed the May 2025 [NAME] unit refrigerator/freezer temperature log and noted there were no refrigerator/freezer temperatures documented for 5/725, 5/8/25, 5/16/25, and 5/21/25. Surveyor also received and reviewed the May 2025 Turnberry unit refrigerator/freezer temperature log and noted the log only contained temperature documentation for 5/3/25. A June 2025 log for the Turnberry unit was not provided to Surveyor.
On 6/11/25 at 11:05 AM, DD-E approached Surveyor and confirmed the facility did not have a June 2025 record of refrigerator and freezer temperatures for the Turnberry unit.
On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated staff should follow the Wisconsin Food Code for policies and procedures regarding food storage, dating, hot/cold food cooked and holding temperatures, and daily refrigerator and freezer temperatures as well as dishwashing sanitization procedures. DD-E indicated staff were probably not aware of the Wisconsin Food Code and indicated DD-E would share the information with staff.
Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 78 residents residing in the facility.
Staff did not ensure time/temperature control foods were labeled with open and use-by dates and/or discarded when they expired.
Staff did not wear hair restraints consistently in the kitchen.
Staff did not follow safe food cooling protocol.
Staff were unaware of temperature requirements when testing parts per million (PPM) of the sanitizing solution.
Unit kitchen dishwashers were not consistently monitored for appropriate temperatures.
Holding and cooking temperature logs for food served to residents were incomplete.
Findings include:
Open/Unlabeled/Undated/Expired Food:
The 2020 Wisconsin Food Code documents at 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking: (A) Except when packaging food using a reduced oxygen packaging method as specified under § 3-502.12 and except as specified in (E), (F), and (H) of this section, refrigerated, ready to eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature and time combination of 5 degrees Celsius (C) (41 degrees Fahrenheit (F)) or less for a maximum of 7 days. The day of preparation shall be counted as day 1 .(2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: .(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section .Disposition: (A) A food specified under 3-501.17 (A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17 (A) Except time that the product is frozen; (2) Is in a container or package that does not bear a date or day.
The facility's Safe Food Storage policy, revised 9/2017, indicates: .Food brought into the facility will be properly labeled and dated the day the item is brought into the facility. Routine inspections will be made to unit refrigerators. All efforts of staff are to ensure safe food storage of any food items stored on units and/or in resident rooms .The following procedure will be applied to all unit refrigerators: Inspected daily by household personnel .Items used or opened will be kept a maximum of three days .Beverages and food items provided by food service may be stored in the refrigerator for use by household staff. When cans and bottles are opened, they must be dated with the date the product was opened and covered properly with covers provided .
On 6/9/25 at 9:35 AM, Surveyor began an initial kitchen tour with Director of Dining (DD)-E who indicated the facility follows the Wisconsin Food Code. During the tour, Surveyor and DD-E observed the following:
Dry Storage:
~ One container of yellow cake mix dated 4/16 with no use-by date
~ One container of Krusteaz pancake mix dated 11/11 (open date per DD-E) with no use-by date
~ One container of vanilla pudding dated 6/3 (open date per DD-E) with no use-by date
~ One container of cocoa powder dated 3/16 with no use-by date
~ Two containers of almonds (one dated 12/19 and the other dated 6/27) with no use-by dates
~ One container of chocolate chips dated 4/12/25 with no use-by date
~ One container of powdered sugar dated 6/7 with no use-by date
~ One gallon of liquid smoke dated 11/8 with no use-by date
~ One undated container of potatoes
~ One container of angel food mix dated 2/26 with no use-by date
~ One container of split peas dated 5/19 with no use-by date
~ One container of spaghetti noodles dated 5/19 with no use-by date
~ One container of barley dated 3/12 with no use-by date
~ One container of stuffing mix dated 6/2 with no use-by date
~ One container of potato pancake mix dated 6/3 with no use-by date
~ One container of potato pearls dated 6/4 with no use-by date
~ One container of spaghetti noodles dated 5/19 with no use-by date
~ One package each of beef gravy, pork gravy, chicken gravy, and turkey gravy with various open dates and no use-by dates
Main/Walk-In Cooler:
~ Three packages of shredded cheese (two dated 6/5 and one dated 6/8) with no use-by dates
~ Eight packages of wrapped cheese slices dated 6/3 with no use-by dates
~ One container of pears dated 6/9 with no use-by date
~ A tub with several raw racks of ribs in a plastic bag that was open to air dated as pulled from the freezer on 6/6 with no use-by date
~ Two packages of raw brats with a pulled date of 6/8 and no use-by date
~ Five packages of precooked chicken with pulled dates of 6/8 and no use-by dates
~ One container with 34 servings of cooked BBQ pork dated 2/4 and pulled 6/8 with no use-by date
~ One package of liquid eggs dated 6/4 with no use-by date
~ One package of cooked turkey cooked 5/11 and pulled 6/9 with no use-by date
Reach-In Cooler:
~ One container of pureed bread dated 6/7 with no use by date
~ One container of egg salad dated 6/8 with no use-by date
~ One container of pureed tomato dated 6/8 with no use-by date
Freezer:
~ Four tubs with numerous packages of cooked and wrapped roast beef dated between January and June with no use-by dates
~ One tub with packages of cooked and wrapped turkey with various dates and no use-by dates
~ Numerous packages of cooked ground hamburger with various dates and no use-by dates
~ Two containers of cooked Swedish meatballs (dated 4/27 and 5/14) with no use-by dates
~ Three containers of cooked spaghetti meat sauce (dated 3/22, 3/27, and 6/3) with no use-by dates
~ Four containers of cooked diced ham (one dated 4/25/25, one dated 5/30, and two dated 5/6) with no use-by dates
~ One container of cooked ground pork dated 6/8 with no use-by date
~ Two containers of beef stock dated 6/4 with no use-by dates
~ One container of 20 servings of cooked Sloppy Joes dated 2/2/25 with no use-by date
~ One container of ham stock dated 6/3 with no use-by date
~ One container of poppy seed butter blend dated 6/10/25 with no use-by date
~ Three large loaves of raw meatloaf dated 3/27 with no use-by dates
During the initial tour on 6/9/25 at 9:35 AM, Surveyor interviewed DD-E who did not know the dating policy or use-by dates for dry good items. DD-E indicated DD-E had started the process of completing Certified Dietary Manager training. When Surveyor asked how staff know the use-by dates for open and/or made items, DD-E indicated staff would not know the use-by dates and the facility needed to establish a new process. DD-E indicated use-by dates in the cooler are three days but also indicated DD-E was not sure of the use-by dates for some of the items. DD-E indicated DD-E was not sure of the use-by dates for items in the freezer but thought six months for the roast beef. DD-E could not locate the facility's dating policy and indicated DD-E would keep looking.
On 6/10/25 at 11:08 AM, DD-E provided Surveyor with a Food Storage Chart printed from FoodSafety.gov and stated the facility uses the chart but follows the Wisconsin Food Code as their policy.
Unit Kitchens:
On 6/9/25 at 10:06 AM, Surveyor toured the [NAME] unit kitchen and observed the following items in the refrigerator:
~ One open container of Grove brand apple juice dated 4/5/25
~ One open and undated container of [NAME] brand sliced strawberry topping
~ Three unopened and undated containers of [NAME] brand sliced strawberry topping
~ One open and undated container of Half and Half
Surveyor observed the following items in the freezer:
~ One undated bag of English muffins
~ Three undated bags of waffles
~ One open and undated jar of Smucker's brand strawberry jam
~ One undated bag of sausage patties
Surveyor also observed several prepackaged and vacuum-sealed bags with the following pureed items:
~ One package of pears (date packaged 10/7/24), one package of pears (dated packaged 12/2/24) and four packages of pears (dated packaged 10/25/24)
~ One package of berries (dated 1/20/25) and five packages of berries (dated packaged 12/31/24)
~ Eight packages of bacon (labeled packaged 1/20/25)
~ Nine packages of [NAME] (labeled packaged 2/12/25)
~ Three packages of [NAME] (labeled packaged 2/6/25)
Surveyor noted each prepackaged pureed item did not contain a use-by date.
On 6/9/25 at 11:44 AM, Surveyor toured the Turnberry unit kitchen and observed the following items in the refrigerator:
~ One open and undated bottle of pear juice
~ One open and undated bottle of orange juice
~ One open and undated jar of concord grape jelly
~ One open and undated bottle of cranberry juice
~ Two undated cartons of strawberries
~ One open and undated raspberry Danish
~ One open and undated bottle of white grape juice
~ One open and undated jar of mayonnaise
~ One open and undated jar of Smucker's brand strawberry jam
~ One open and undated bottle of BBQ sauce
~ One open and undated bottle of Caesar salad dressing
~ One unopened bag of prepackaged hard-boiled eggs with a use-by date of 5/31/25
~ Four bags of grapes with no received, open, or use-by dates
Surveyor observed the following items in the freezer:
~ One undated raspberry Danish
~ Three undated bags of waffles
~ Multiple hashbrown patties in an undated one-gallon plastic bag
~ Three undated gallon-size plastic bags of egg patties
~ Three undated gallon-size plastic bags of sausage patties
Following the observations, Surveyor interviewed Certified Nursing Assistant (CNA)-I who indicated kitchen staff bring the items to the units. CNA-I indicated the items should be dated when they arrive. CNA-I indicated Homemakers or CNAs who work in the kitchen are responsible for labeling items when they are opened and should indicate when the items should be used by.
During a tour of the Turnberry kitchen on 6/10/24 at 8:22 AM, Surveyor observed undated raspberry Danish served to residents during breakfast.
During a tour of the [NAME] unit kitchen on 6/10/25 at 8:42 AM, Surveyor noted the following items were added to the refrigerator from the previous observation on 6/9/25:
~ Five coffee creamers (one was open and all were undated)
On 6/10/25 at 11:13 AM, Surveyor interviewed DD- E who indicated the prepackaged pureed items came from the vendor. DD-E indicated Homemakers and CNAs are responsible for labeling items when opened. DD-E indicated the facility follows their policy and the foodsafety.gov Cold Food Storage chart for cold storage use-by dates. Surveyor noted fully cooked, vacuum-sealed at plant unopened food contained a use-by date of 1-2 months for the freezer. DD-E indicated the prepackaged pureed foods should be discarded.
On 6/10/25 at 12:13 PM, Surveyor observed the following items in the [NAME]/Sunny Creek second floor kitchenette with Homemaker (HM)-C:
Cooler:
~ One container of egg salad dated 6/8 with no use-by date
~ One package of pickles dated 6/4 with no use-by date
~ One container of egg custard dated 6/9 with no use-by date
~ One container of sour cream dated 5/30 with no use-by date
~ One unlabeled container of a pasta salad (per HM-C) dated 6/9 with no use-by date
~ One unlabeled package of cut tomatoes (per HM-C) dated 6/2 with no use-by dates
~ One unlabeled package of lettuce (per HM-C) dated 6/7 with no use-by date
~ One unlabeled package of pork cutlets (per HM-C) dated 6/4 with no use-by dates
~ One unlabeled package of two browning heads of lettuce (per HM-C) dated 5/20 with no use-by date
~ One unlabeled package with two heads of lettuce (per HM-C) dated 6/3 with no use-by date
~ One package of carrots dated 6/2 with no use-by date
~ Two packages of shredded cheese dated 5/26 with no use-by dates
~ One package of cooked bacon dated 6/10 with no use-by date
~ One package of hashbrowns dated 6/10 with no use-by date
~ One unlabeled and uncovered pan of cherry dessert (per HM-C) dated 6/3 with no use-by date
~ One unlabeled pan of white cake (per HM-C) dated 6/9 with no use-by date
~ One unlabeled pan of banana cream dessert (per HM-C) covered with ripped aluminum foil and with a knife in the dessert dated 6/8 with no use-by date
~ One unlabeled pan of orange Jell-O (per HM-C) dated 6/8 with no use-by date
Freezer:
~ Four packages of egg patties (dated 5/1, 5/1, 5/17, and 6/1) with no use-by dates
~ One package of hot dogs dated 6/9 with no use-by date
~ Three packages of sausage patties (one dated 5/8 and two dated 5/26) with no use-by dates
~ One unlabeled and undated package of hashbrown patties (per HM-C)
~ One open, unsealed, unlabeled, and undated package of uncooked bacon (per HM-C)
~ Two packages of ham (dated 11/24 and 1/21) with no use-by dates
On 6/10/25 at 12:31 PM, Surveyor interviewed HM-C who indicated food in the unit refrigerators and freezers should be labeled and dated and fully covered. As Surveyor and HM-C pulled out the lettuce, tomatoes, and desserts, HM-C indicated the items were expired and should have been discarded after three days. HM-C indicated HM-C was embarrassed by the unlabeled, undated, and expired food in the refrigerator and was not aware of the use-by dates. HM-C also indicated it was not acceptable for staff to leave a knife in the dessert.
On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated DD-E will work on sharing the Wisconsin Food Code with staff. DD-E indicated staff should follow the Wisconsin Food Code for use-by dates and dating food items.
Hair Restraints:
The 2022 Wisconsin Food Code documents at Hair Restraints 2-402.11 Effectiveness:.(B) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single-use articles.
The facility's Food Service Personnel Management policy, revised 2/2025, indicates: To achieve standards set by federal, state and local agencies .3. Personal Hygiene: .b. A hair net must be worn at all times when handling or preparing food to prevent hair from contaminating food or surfaces. If staff are working on the households on a side where food is not out, hairnets do not need to be worn (example: doing dishes or getting a resident water) .f. Long hair must be pulled back securely - no scarves or flowers .
During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor noted DD-E's bangs covered DD-E's forehead and were not restrained while DD-E prepared food. Surveyor also noted approximately 3 to 4 inches of the sides of DD-E's hair were pulled out of the hair restraint near DD-E's ears.
On 6/9/25 at 11:58 AM, Surveyor observed CNA-F walk behind the [NAME]/Sunny Creek kitchen area without a hair restraint when HM-C was serving food. There was dessert on the counters on both sides of the kitchen when CNA-F walked by.
On 6/10/25 at 8:52 AM, Surveyor observed HM-C serve food in the [NAME]/Sunny Creek kitchen with HM-C's bangs exposed in the front, sides, and back of HM-C's hair restraint.
On 6/10/25 at 11:38 AM, Surveyor observed CNA-D walk behind the [NAME]/Sunny Creek kitchen area without a hair restraint when staff were preparing food. CNA-D retrieved drinks for residents. At 11:40 AM, CNA-D asked HM-C for a hair restraint. HM-C showed CNA-D where the hair restraints were kept. CNA-D applied a hair restraint and kept working in the kitchenette.
On 6/10/25 at 11:41 AM, Surveyor interviewed CNA-D who indicated CNA-D had not worn a hair restraint before 6/10/25. When asked why CNA-D put on a hair restraint that day, CNA-D indicated CNA-D was told by management that CNA-D needs to start wearing a hair restraint in the kitchenette.
On 6/10/25 at 11:52 AM, Surveyor observed CNA-F enter the [NAME]/Sunny Creek kitchenette while food was being served. CNA-F wore a hair restraint, however, 3 to 4 inches of CNA-F's hair was not restrained on the right side.
On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated DD-E will work on sharing the Wisconsin Food Code with staff. DD-E indicated staff need to wear hair restraints in the kitchen and kitchenettes when they prepare, serve, and are around food.
Safe Cooling:
The 2022 Wisconsin Food Code documents at section 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57° Celsius (C) (135° Fahrenheit (F)) to 21° C (70° F); and (2) Within a total of 6 hours from 57° C (135° F) to 5° C (41° F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5° C (41° F) or less.
The 2022 Wisconsin Food Code documents at section 3-501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods.
The facility's Post Cooking Cooling policy, dated 2/16/22, indicates: To prevent bacterial growth and ensure resident safety, all potentially hazardous foods that require cooling must be cooled rapidly and monitored to meet time/temperature standards. 1. Temperature check after cooking. Immediately after cooking is completed, staff must: measure the internal temperature of the food using a calibrated, sanitized food thermometer. Record the time, temperature, food item, and staff initials on the Cooks Temp Log. 2. Initiate cooling. Begin cooling immediately using one of the following approved methods: Refrigerator Cooling, .Freezer Quick Cool, .3. Storage after cooling. Once the food has reached 41° F or below: Cover, label with product name, cooling completion date, and use-by date. Store according to FIFO (first in, first out) procedures.
During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor and DD-E observed the following cooked and cooled foods in the walk-in freezer and walk-in cooler:
Freezer:
~ Four tubs with numerous packages (30+) of cooked and wrapped roast beef dated between January and June
~ One tub with packages of cooked and wrapped turkey with various dates
~ Numerous packages of cooked ground hamburger with various dates
~ Two containers of cooked Swedish meatballs (dated 4/27 and 5/14)
~ Three containers of cooked spaghetti meat sauce (dated 3/22, 3/27, and 6/3)
~ Four containers of cooked diced ham (one dated 4/25/25, one dated 5/30, and two dated 5/6)
~ One container of cooked ground pork dated 6/8
~ One container of 20 servings of cooked Sloppy Joes dated 2/2/25
Cooler:
~ One container of pasta salad dated 6/9
~ One package of cooked pork cutlets dated 6/4
~ One package of cooked turkey dated 5/11
~ One container of 34 servings of cooked BBQ pork dated 2/4
During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor interviewed DD-E who indicated the facility does not use food cooling logs. When asked how staff track cooked food cooling, DD-E indicated staff do not measure or track food cooling.
On 6/11/25 at 9:34 AM, Surveyor interviewed DD-E who indicated DD-E was not aware of the cooked food cooling requirements in the Wisconsin Food Code.
Sanitizing Solution:
The 2022 Wisconsin Food Code documents at section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.
The facility's Maintenance, Sanitization and Safety policy, dated 1/2018, indicates: Maintenance, sanitization, and safety according to federal, state, and local agencies .B. Sanitization. 1. The Food Service Manager, with the help of the Registered Dietitian, is responsible for the supervision and training of employees in proper sanitization within the Food Service Department.
During the initial kitchen tour on 6/9/25 at 9:35 AM, Surveyor reviewed the Dish Machine Temperature Log which contained a column for sanitizer testing. Surveyor noted every entry in the sanitizer testing column for May and June 2025 read 200. The log did not contain
Jun 2024
1 deficiency
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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff app...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff applied a foot pedal to a wheelchair during transport of the resident to prevent an accident for 1 of 3 sampled residents (R1) reviewed for accidents.
Findings included:
R1 was admitted to the facility on [DATE]. The Resident Face Sheet revealed the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following a cerebral infarction affecting the right side, vascular dementia, pain, and weakness.
The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/20/24, revealed R1 had a Staff Assessment for Mental Status (SAMS), which revealed the resident had moderately impaired cognitive skills for daily decision making. The MDS indicated the resident used a wheelchair for mobility and was dependent on staff for activities of daily living.
R1's Care Plan, with a problem start date of 10/11/22 and revised on 05/14/24, documented the resident used a wheelchair to get around.
The facility's undated investigation report revealed on 05/02/24 at 9:30 AM, staff noted R1 had increased pain on their right side, mostly in their leg. Per the report, later in the day on 05/02/24, it was witnessed that CNA C (Certified Nursing Assistant) wheeled R1 out of their room to the dining room without a foot pedal on the right side of the wheelchair. R1 put their right foot down while the wheelchair was in motion, and R1's foot went backwards. The report revealed during a routine visit by the Nurse Practitioner, on 05/07/24, the resident grimaced when their ankle was assessed and an x-ray was ordered.
The x-ray report revealed R1 had moderate malleolar soft tissue swelling, acute distal fibular shaft fracture (the most common type of ankle fracture, usually the result of inversion), and an acute medial malleolus (lowest part of the long bone of the leg) fracture. According to the report, the facility was unable to determine how the fracture occurred because R1's pain began prior to the staff not utilizing the foot pedal.
The investigation report revealed R1's care plan was updated to ensure staff knew they needed to place the right foot pedal on the resident's wheelchair.
During an interview on 06/24/2024 at 3:42 PM, CNA C stated she propelled R1 from their room to the dining room without the wheelchair pedal under R1's right foot. CNA C stated she noticed R1's right foot was under the wheelchair, when the resident cried out. CNA C stated she rolled the wheelchair backwards and got R1's foot out from under the wheelchair. CNA C stated LPN D (Licensed Practical Nurse) and RN E (Registered Nurse) came over, and LPN D went to R1's room to get the foot pedal. CNA C stated LPN D witnessed R1's foot under the wheelchair.
During an interview on 06/25/24 at 10:35 AM, R1's Responsible Party (RP) stated when they pushed R1 in their wheelchair, the right wheelchair foot pedal was always in place. The RP stated R1 could propel themselves in the wheelchair with their left foot. The RP stated R1's right side was affected by a stroke.
During an interview on 06/25/24 at 1:16 PM, RN E stated she heard R1 cry out, and went to ask R1 what was wrong. RN E stated the resident had a habit of crying out and was difficult to understand. RN E stated she did not witness R1's foot under the wheelchair, but did see that R1 did not have the right foot pedal on their wheelchair. RN E stated R1 did not seem to be in pain, after the incident, and went to the common area and played cards.
During an interview on 06/25/24 at 2:00 PM, DON B (Director of Nursing) stated the resident had increased pain prior to the incident and she would not have expected an x-ray right away if the resident did not complain of pain.
During an interview on 06/25/24 at 2:06 PM, NHA A (Nursing Home Administrator) stated accidents would happen and she expected staff to learn from the accident through education so that it would not happen again.
During a return telephone call on 06/26/24 at 7:03 PM, LPN D stated she was in the dining room with her supervisor, RN E, when she heard R1 cry out. LPN B stated she turned around and saw R1's foot under the wheelchair and CNA C pulled the wheelchair back. LPN D stated she went to R1's room to get the right foot pedal for the resident's wheelchair. LPN D stated she did not assess R1's leg because the resident always had right leg pain and swelling, so it would be hard to determine if symptoms were the result of the incident. LPN D stated she had the Advanced Practice Nurse Practitioner look at R1's ankle, and an x-ray was ordered.
Feb 2024
1 deficiency
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 food was prepared safely and temperatures taken in 5 of 5 household kitchens. This deficient practice has the potential ...
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Based on observation, record review, and interview, the facility did not ensure food was prepared safely and temperatures taken in 5 of 5 household kitchens. This deficient practice has the potential to affect 80 of the 82 residents currently residing in the facility who receive their meals from the household kitchens.
* End of service temperature checks were not being completed 4 times a month on AM and PM shift.
* Temperatures were not being taken for breakfast food cooked in the individual household kitchens.
Findings:
The facility policy, entitled Food Preparation, revised 2/2009, states, D. A thermometer is used during food preparation to insure proper cooking temperatures for all food items. H. The Food Service cook record the temperature of the food at each meal to determine if the food is cooked and maintained at correct temperature.
The facility policy, entitled Steam Table, Use of, revised 3/2017, states H. Complete end of service temperature check sheet, this is done once a week on AM and PM shift.
On 02/21/24 at 07:41 AM, Surveyor spoke to Dietary Manager (DM)-C regarding observing temperature of food at the holding site. DM-C informed Surveyor that temperatures are taken at the end of service of the last plate served and that this end temperature is taken 4 times a month on both AM (lunch) and PM (Dinner) service.
On 02/21/24 at 07:55 AM, Surveyor interviewed Homemaker-D on Woodland/Sunnyfield Unit who was serving breakfast that consisted of French toast bake and bacon. Surveyor asked where the French toast bake and bacon were cooked. Homemaker-D confirmed that both items were cooked in the unit's kitchen. Surveyor asked if a temperature was taken of cooked food items prior to service and Homemaker-D stated they were not as temperatures are taken at the end of service once a week. Homemaker-D pointed out an End of Service Temperature Check Sheet located on the refrigerator. Surveyor notes an end of service temperature taken on 2/10/24 AM shift and 2/19/24 on AM shift. Surveyor asked Homemaker-D when eggs are made to order are the eggs tempt prior to service? Homemaker-D stated no. Homemaker-D stated that they use a binder which has all the recipes and bake times. They follow these instructions to prepare the food and then serve it. There is no documentation of any PM shift end of service temperature checks completed.
On 02/21/24, at 08:20 AM, Surveyor requested the food temperature policy from the Nursing Home Administrator (NHA)-A.
On 02/21/24 at 01:39 PM, Surveyor spoke with Homemaker-E on TurnBerry unit. Surveyor asked Homemaker-E where the French toast back and bacon were cooked for the mornings breakfast. Homemaker-E stated that most breakfast items are cooked right in the kitchen on the units. She stated that temperatures are not taken after making the food since they are following the recipe and cook time is in the binder provided. Homemaker-E showed the binder to Surveyor which gave instructions for how to prepare and cook food items and it does reference the internal cooking temperature of the food item. Surveyor asked how do they know the food items has reached the appropriate internal temperature if they are not taking a temperature at the end of cooking? Homemaker-E stated that they follow the cooking time and that it's assumed the item is cooked thoroughly. Surveyor reviewed the End of Service temperature Check Sheet located on the refrigerator and noted documentation of an end of service temperature taken on 2/3/24 on AM shift, 2/8/24 on AM shift and 2/17/24 on AM shift. There is no documentation of a PM shift end of service temperature taken on PM shift for those days.
On 02/21/24, at 01:45 PM, Surveyor interviewed DM-C regarding breakfast food prepared and make on the unit kitchens. DM-C stated that staff should be taking temperatures of breakfast food after they are done cooking it. Surveyor informed DM-C of the concern that there does not appear to be a temperature log for breakfast food. The only temperature logs in the unit kitchens are the End of Service Temperature Check Sheet and those do not document breakfast items. DM-C stated she would look for logs.
On 02/22/24, at 08:34 AM, Surveyor spoke with NHA-A regarding the concern that there is no evidence that food cooked in the unit kitchens are having their temperature taken prior to service to ensure that food has been cooked to the proper internal temperature. Surveyor also explained that it does not appear that staff are following policy to complete the End of Service Temperature Check Sheet per policy as temperature checks are not being completed 4 times per month on both AM and PM shift. NHA-A states she would look into this.
On 02/22/24, at 08:56 AM, NHA-A provided Surveyor with copies of the End of Service Temperature Check Sheets from each of the unit kitchens. NHA-A stated that there is a lot of missing temperatures and staff were not following the instructions therefore they will need to do re-education.
On 02/22/24, at 10:02 AM, DM-C confirmed that there is not temperature log for breakfast food cooked on the units.
No additional information was provided.
Nov 2022
3 deficiencies
1 Harm
SERIOUS
(G)
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 interview and record review, the facility did not ensure that Residents without a Pressure Injury (PI) do not develop 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 without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 1 (R9) of 3 Residents reviewed for pressure injuries.
* R9 was admitted to the facility on [DATE] with diagnoses which included a right hip fracture. The admission body check documents a 3.0 x 1.8 cm (centimeter) purple area that is not open potentially indicating the presence of a DTI (deep tissue injury).
The wound assessment 8/9/22 documents a Stage 2 PI with 90% slough & 10% epithelial tissue. R9's pressure injury was not staged correctly as a Stage 2 pressure injury does not include slough.
The 8/17/22 wound assessment continues to stage R9's pressure injury as a Stage 2 with 100% granulation tissue. R9's pressure injury was staged incorrectly as a Stage 2 doesn't contain granulation tissue.
On 8/18/22 R9's skin integrity care plan was revised.
The wound assessment dated [DATE] staged the PI as Unstageable with the wound bed being 100% slough. There were no revisions to R9's care plan after 8/18/22.
On 8/25/22 the nurses note documents NP (Nurse Practitioner) updated per facility policy for an order for a wound culture.
The wound specimen from coccyx collected on 8/25/22 and verified on 8/30/22 documents pseudomonas aeruginosa & mixed aerobic flora.
On 8/30/22 during treatment change, the dressing was completely saturated with a foul odor. An order was received on 8/30/22 for Cipro 500 mg twice daily for 7 days.
The wound assessment dated [DATE] documents Stage 4 with 50% granulation, 50% slough, and exposed bone. There was no revision to R9's care plan.
On 10/27/22, R9's pressure injury had an increase in drainage with the drainage being described as cloudy tan serosanguineous and a slight odor. A wound culture and sensitivity were ordered.
On 10/30/22, lab results revealed MRSA (Methicillin-resistant Staphylococcus aureus) in R9's pressure injury and an antibiotic was again ordered. On 10/31/22, a second antibiotic was ordered.
R9's wheelchair & recliner cushion and mattress as observed by Surveyor are not appropriate for a Stage 4 pressure injury.
Findings include:
The facility policy and procedure last revised on 8/19 titled: Prevention and Care of Pressure Injuries indicates under policy: All residents that are at risk for developing a pressure injury will have preventative measure implemented to prevent and or aid in the healing of pressure injuries.
Under Pressure Injury Grading System for Stage II (2) documents Partial thickness loss of dermis presenting as a shallow open ulcer with red of sic (or) pink wound bed, without slough. May also present as an intact or open/ruptured blister. This stage should not be used to describe perineal dermatitis, maceration, or excoriation.
Under recommendations for treatment and care for Stage III (3) and Stage IV (4) documents
Desired outcome: Promote healing and reduce bacterial growth, evaluate, and monitor. All recommendations per MD (medical doctor) order.
1. Keep wound clean by using Wound Cleanser or normal saline.
2. Reduce bacterial growth: Local Infection - (edema, pus, erythema, exudates, etc.) Topical anti-microbial therapy if applicable. Systemic infection - (chills, fever, elevated WBC (white blood count)) obtain order for culture and/or antibiotic therapy, if applicable.
3. Adequate nutritional intake, ongoing consultation with Dietician.
4. Assure a low-pressure environment - pressure reducing mattress,
R9 was admitted to the facility on [DATE] with diagnoses including right hip fracture, HTN (hypertension), and chronic congestive heart failure.
The hospital Discharge summary dated [DATE] includes documentation for skin indicating: no evidence of rash or excoriations.
Review of the undated and unsigned admission body check includes a circle at the coccyx area on the diagram with documentation of 3.0 cm (centimeter) x 1.8 cm purple without open area. The description on this admission body check would indicate R9 has a potential DTI (deep tissue injury).
The nurses note dated 8/9/22 documents Patient is A&O x4 (alert and orientated times four) with periods of forgetfulness. Is able to make her needs known. Is very HOH (hard of hearing). Wears Bil (bilateral) hearing aids which does not seem to help. Transfers with 1A (one assist) [NAME] steady. Denies pain upon this assessment. VSS (vital signs stable), HRR (heart rate regular), no abnormal sounds noted. No cough or SOB (shortness of breath) noted. LSCTA (lung sounds clear to auscultation). Abd (abdomen) soft n/t (non-tender) with BS (bowel sounds) x4. Scattered bruising to BUE (bilateral upper extremities). Abrasion to her R (right) elbow and coccyx with treatment done. Protective cream applied to coccyx. Continent of B&B (bowel and bladder) with clear yellow urine noted. NP (non pitting) edema noted to BLE (bilateral lower extremities). Is on a general NAS (no added salt) diet. Surgical dressing to R (right) hip with small amount of drainage noted. Area outlined to monitor. Call light and pendent within reach.
The wound assessment dated [DATE] documents Stage II (2), location not identified. Measurements are 4 cm x 2.3 cm, exudate is light serosanguineous and wound bed is 90% slough & 10% epithelial tissue. For wound edges/margins the assessment documents Edge attached to base; Irregular wound edges; Macerated soft. Under comments documents, Area was cleansed with wound cleanser, hydrogel applied to wound bed, skin prep to peri wound and covered with an Optifoam dressing. Minimal amount of drainage noted. Surveyor noted R9's pressure injury was incorrectly staged, as a Stage 2 pressure injury does not have slough and PI should have been staged as Unstageable. Surveyor also noted the documentation on what R9's skin conditions were upon admission has conflicting information on what R9's coccyx condition was on admission.
The APNP (Advance Practice Nurse Prescriber) rehab admission note dated 8/11/22 does not include documentation of R9's pressure injury.
On 8/11/22, the coccyx treatment for hydrogel, skin prep, and Optifoam was discontinued, and a new treatment was ordered to cleanse the wound with wound cleanser or soap & water, pat dry, and apply Chymosin barrier cream twice a day & prn (as needed).
The Alteration in skin integrity care plan with a start date of 8/11/22 & last reviewed/revised on 10/27/22 documents the following approaches:
* Equagel cushion to be in place where I am sitting in recliner or wheelchair. Start date of 8/11/22.
* SKIN: Help turn/reposition every 2 hours. Side to side when in bed with pillow support. Start date of 8/11/22.
* Follow Standard of Care Protocol for Skin Care. Start date of 8/11/22 & discontinued on 10/13/22.
The Standard of care protocol for skin has approaches of:
Complete a body check on all admissions, readmissions, and before and after ER (emergency room) visits/hospitalizations.
Complete a Braden Scale upon admission/readmission and every week for three weeks thereafter, quarterly, and change of condition.
Thorough skin inspection to be done weekly during bath by the nurse who should fill out a skin audit observation after the bath.
A standard pressure relief cushion should be in the chair and a standard pressure relief mattress on the bed.
Should keep skin clean and dry.
Should apply moisture barrier cream after resident has an incontinent episode.
Apply sunscreen, sunglasses, and hat with a brim, if it's anticipated that there could be prolonged exposure to the sun.
Follow basic good skin care which includes washing, rinsing, and dry thoroughly should be provided to residents requiring assistance with personal hygiene.
Be aware of any allergies or sensitive skin when ordering lubricants or creams.
Reposition residents with pillows behind the back and between the legs. Avoid positioning directly on the hip bone.
Off load resident's heels in bed.
If braces, casts, or splints are used, daily skin checks should be done to monitor for s/s (signs/symptoms) skin breakdown.
Weekly measurements of all wounds (surgical wounds, pressure ulcers, skin tears, venous stasis ulcers, abrasions, lacerations, etc.) should be done until healed. The measurements and progress should be documented.
The Dietitian and WCC/RN (Wound Care Certified/Registered Nurse) should be updated if a resident has a Stage 1 or greater ulcer for dietary interventions and wound treatment.
The resident's physician and family or POA-HC (power of attorney health care) should be updated on skin integrity.
Treatments should be according to the physician's order.
A referral to the Wound Clinic for consult as needed.
* SKIN: Please move the Equagel cushion to the recliner or wheelchair. Start date of 8/18/22.
Surveyor noted there are no revisions to R9's skin integrity care plan after 8/18/22.
The wound assessment dated [DATE] documents Stage II (2). Measurements are 3.2 cm x 1.5 cm x 0.1 cm, exudate is light serous and wound bed is 100% epithelial tissue. For wound edges/margins the assessment documents Edge attached to base; Irregular wound edges.
The nurses note dated 8/11/22 documents Right elbow skin tear almost healed, no longer needs a dressing. Tx (treatment) changed to apply skin prep to right elbow BID (twice a day), to leave steri-strip in place. Stage II coccyx wound treatment changed from hydrogel with Optifoam dressing to applying Chamosyn (sic) barrier cream BID and PRN (as needed). NP (Nurse Practitioner) updated per facility policy to wound care dressing treatment changes. To off-load pressure to buttock with repositioning Q2 (every two) hours and turning side to side with pillow support Q2 hours while in bed, Equagel cushion to be in place in recliner or wheelchair when pt (patient) sitting in it. Educations provided to pt about importance off off-loading pressure to buttock area, pt verbalized understanding.
The physician order dated 8/11/22 documents 1 packet Juven BID (twice a day) ok to mix with juice or water and 1 oz (ounce) liquid protein (active) supplement BID ok to mix with Juven. On 8/15/22 the order was changed from BID to QD (every day).
R9's admission MDS (minimum data set) with assessment reference date of 8/16/22 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R9 is coded as not having any behaviors including refusal of cares. R9 requires limited assistance with one-person physical assist for bed mobility & ambulation, extensive assistance with one-person physical assist for transfer & toilet use, and is independent with set up for eating. R9 is at risk for pressure injuries and is coded as having one Stage 2 pressure injury, present upon admission.
The pressure injury CAA (care area assessment) dated 8/18/22 under analysis of findings documents R9 was admitted with a stage II pressure injury to her coccyx. She also has a skin tear to her right elbow. Treatments are done as ordered. Interventions in place to reduce pressure. According to the hospital Discharge summary dated [DATE], R9 underwent an ORIF (open reduction and internal fixation) of her right hip fracture which was sustained from a fall. Her incision has no s/s (signs/symptoms) of infection. During the seven-day look back period, she was continent of bowel per vitals and occasionally incontinent of bladder per POC (plan of care). Staff assist with incontinence care. Her Braden score was 18. She needs limited assist with bed mobility per POC. A pressure reduction cushion is in the chair, and a standard pressure relief mattress is on the bed. Skin is inspected with cares, and a skin audit is done weekly. The dietician has met with her and completed the nutritional assessments. PT, OT, and ST (physical therapy, occupational therapy, and speech therapy) have done their evaluations (see PT/OT/ST assessments). She is participating in therapies as ordered to regain her strength and endurance and to improve her mobility so she can be more independent with bed mobility, transfers, and ambulation.
The wound assessment dated [DATE] documents Stage II (2). Measurements are 4 cm x 1.5 cm, tissue type is granulation. Surveyor noted R9's pressure injury is incorrectly staged, as a Stage 2 does not have granulation tissue. The pressure injury should have been staged as a Stage 3.
The initial physician visit dated 8/17/22 under review of systems includes documentation of Reports: buttocks pain does have history of previous right superior and inferior pubic rami fractures. Under objective for musculoskeletal documents: Dressing over right lateral hip with just small soiling no tenderness over dressing. There is no documentation or reference regarding R9's coccyx pressure injury.
The wound assessment dated [DATE] documents Stage II (2). Measurements are 4.5 cm x 2 cm, exudate is light serosanguineous and wound bed is 100% epithelial tissue. For wound edges/margins the assessment documents Edge attached to base; Macerated/soft; Well defined wound edges. Under comments it is documented Stage 2 to coccyx is stable. Minimal amount of serosanguineous drainage noted. Treatment order changed to cleanse area with wound cleanser, apply hydrogel to wound bed, cover with Optifoam dressing. QOD (every other day) and PRN (as needed). Writer encouraged patient to utilize wheelchair cushion while sitting in recliner.
R9's skin integrity care plan was revised on 8/18/22 with addition to Please move the Equagel cushion to the recliner or wheelchair. There were no further revisions to R9's skin integrity care plan.
On 8/23/22, the treatment was changed to cleanse wound, apply hydrogel, cover with Optifoam every other day. On 8/26/22 this treatment was changed from every other day to twice daily.
The wound assessment dated [DATE] documents stage as Unstageable Slough and/or Eschar, measurements are 6.5 cm x 6 cm x 0.2 cm, exudate is moderate seropurulent, wound bed is 100% slough, and wound healing status is documented as declining. Surveyor noted there are no revisions to R9's skin integrity care plan.
The nurses note dated 8/25/22 documents Coccyx wound is larger, wound bed covered in slough tissue and is now an Unstageable pressure injury. Drainage is moderate sero-purulent drainage, no odor noted, peri-wound is red, but does blanch. To continue with current dressing change tx and off-loading interventions. NP updated per facility policy for an order for a wound culture.
The wound assessment dated [DATE] documents stage as Unstageable Slough and/or Eschar, measurements are 7.7 cm x 4.4 cm x 2.8 cm, exudate is moderate serous, wound odor is pungent odor, wound bed is 100% slough, wound edges/margins are well defined wound edges, and wound healing status is stable. Under comments documents Slough area detached from R side of wound on R gluteal, exposed 2.8 cm tunneling noted. Treatment order changed per wound nurse recommendations.
On 8/29/22 it is documented in R9's medical record the treatment was changed and indicates it was changed to the Stage 2 coccyx: Cleanse area with wound cleanser, pack tunneled area with Maxorb AG (silver), apply hydrogel slough areas, cover with sacral Optifoam dressing twice a day.
The nurses note dated 8/30/22 documents Patient is A&O x 4 with occasional forgetfulness and confusion. No complaints of pain at time of assessment. Transfers and ambulates with 1A (one assist) using WW (wheeled walker). Heart rate and rhythm regular with murmur. +2 pitting edema to RLE (right lower extremity) and +1 pitting edema to LLE (left lower extremity). Tubigrips applied and BUE elevated when able. Strength is strong and equal with hand grasp and foot press. Unstageable pressure injury to coccyx area which has declined, slough present and tunneling. Treatment done this morning; previous dressing was completely saturated, foul odor present. Call light within reach, safety maintained.
The wound specimen from coccyx collected on 8/25/22 and verified on 8/30/22 documents pseudomonas aeruginosa & mixed aerobic flora.
The nurses note dated 8/30/22 documents NOR (new order received) from APNP for Lasix 20mg (one time), Cipro 500mg BID (twice a day) x7 days, Florastor 250mg BID x10 days, and check BMP (basic metabolic panel) in the morning.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 7.5 cm x 3 cm x 2. cm, exudate is heavy seropurulent, there is no wound odor, wound bed is 50% granulation & 50% slough, wound edges/margins on assessment indicate edge is not attached to base and wound healing status is declining. Under comments documents Undermining 2.0 cm from 2 o'clock-9 o'clock. Slough tissue is lifting. Base of wound granulation tissue with exposed bone.
The nurses note dated 9/1/22 documents Coccyx wound assessed. Wound continues to decline quickly. There is exposed bone at wound base. Wound does appear as a Kennedy ulcer. To continue with current dressing change orders and off-loading interventions. If family agrees to hospice care, goal to be geared towards comfort over wound healing. Surveyor noted there was no documentation that the physician or nurse practitioner were consulted with or notified of this at this time.
The nurses note dated 9/2/22 documents: Patient is A&O x3 (alert and orientated times three) with times of forgetfulness but is able to make her needs known appropriately. VSS (vital signs stable). denies pain unless its during coccyx dressing change. Hand and foot grasps strong and equal. Transfers using 1A (one assist) WW (wheeled walker) and GB (gait belt) and tolerates well. Walks to and from the bathroom and to and from meals. Needs extensive assist with lower ADLs (activities daily living) and dressing. Once set up for grooming she can do that independently. HRR (heart rate regular). Has +1 pitting edema to BLE (bilateral lower extremities), tubi grips are on. Coccyx wound dressing changed this morning and the previous dressing was about half saturated with foul smelling tan colored drainage, the area was cleansed and packed per order. Call light within reach and safety maintained.
On 9/2/22 the treatment remained the same except for instead of covering the pressure injury with a sacral Optifoam dressing, the covering was changed to an Optilock dressing and secure with paper tape. The frequency remained the same at twice a day.
The nurses note dated 9/6/22 documents, Large section of slough/dead tissue has fallen off of wound. Area cleansed and dressing changed.
The social service note dated 9/8/22 documents: Care conference held today, in attendance was resident's daughter (name), son (name), writer, and nursing. Lengthy discussion regarding hospice services and education on their services. Family in agreement with hospice services after discussion with resident and other family members. Resident and family choice for hospice agency is (name.) All questions answered, no concerns at this time.
The nurses note dated 9/8/22 documents: Coccyx wound assessed, measured and dressing change provided. The coccyx wound is stable, wound bed does appear clean, mild odor noted before cleansing, drainage to old dressing seropurulent. Pt (patient) assisted to left side in bed with staff assistance and tolerated dressing change well. To continue with current dressing change tx (treatment) and off-loading interventions.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 6 cm x 6 cm x 2. cm, exudate is moderate purulent, wound odor is mild, wound bed is 80% granulation & 20% slough, wound edges/margins on assessment indicate edge not attached to base and wound healing status is stable. Under comments documents Tunnel at 12 o'clock 4.0 cm, and 1 o'clock 4.5 cm with undermining 2 o'clock-4 o'clock 3.0 cm and 9 o'clock-11 o'clock 1.0 cm.
The note dated 9/12/22 documents, Writer notified by (hospice company) hospice nurse that resident, with her family present, signed onto hospice services this morning. No concerns at this time.
The nurses note dated 9/15/22 documents: Coccyx wound assessed, measured and dressing changed. Wound appears clean with 90% granulation tissue and 10% slough tissue. No odor noted and drainage is moderate serous. Pt tolerated dressing change well. To continue with current dressing change orders and off-loading.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 7.0 cm x 3 cm x 2.5 cm, exudate is moderate serous, there is no wound odor, wound bed is 90% granulation & 10% slough, wound edges/margins indicate edge not attached to base and wound healing status is stable. Under comments documents, Tunnel at 11 o'clock 4.0 cm, and 12 o'clock 3.0 cm with undermining 9 o'clock-10 o'clock 2.0 cm and 1-3 o'clock 2.0 cm.
The significant change MDS with an assessment reference date of 9/21/22 documents a BIMS of 12 which indicates moderately impaired. R9 requires extensive assistance with one-person physical assist for bed mobility, transfer, & toilet use, and requires supervision with set up for eating. R9 is at risk for pressure injuries and is coded as having one Stage 2 pressure injury. Surveyor noted the pressure injury should have been coded as a Stage 4. Surveyor also noted the decline in R9's assessed need for assistance since the admission MDS dated [DATE]. Surveyor noted this decline is not addressed in R9's plan of care.
The Pressure injury CAA dated 9/29/22 under analysis of findings documents R9 was admitted with a stage II pressure injury to her coccyx. Treatments are done as ordered. Interventions in place to reduce pressure. During the seven-day look back period, she was continent of bowel per vitals and frequently incontinent of bladder per POC. Staff provide incontinence care. Her Braden score was 17. A pressure reduction cushion is in the chair, and a standard pressure relief mattress is on the bed. Skin is inspected with cares, and a skin audit is done weekly. The dietician has met with her and completed the nutritional assessments. She is at risk for malnutrition. She has started hospice services due to declining self-care abilities and mobility. Surveyor noted the change in R9's assessed needs for assistance are not reflected in R9's care plan.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 6 cm x 3 cm. There is no depth documented. Exudate is moderate serous, there is no wound odor, wound bed is 90% granulation & 10% slough, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 2.5 cm tunnel from 11 o'clock-1 o'clock, 1.5 cm undermining from 2-4 o'clock and 1.5 cm from 9-10 o'clock.
On 9/22/22 the treatment to the wound bed stayed the same with the covering being changed to a bordered foam sacral dressing or Optilock dressing secured with paper tape. The frequency remained the same at twice a day.
The APNP note dated 9/26/22 under history, present illness includes documentation of: Due to condition with large sacral wound, pt stopped therapy. Discussion with family led to hospice eval with desire for comfort and wound healing Coccyx DTI (deep tissue injury) Open to bone with tunneling. Treated with Cipro x 10 days 8/30/22 due to infection with pseudomonas. It has improved but is still open. Per wound care RN on 9/22 wound is 90% granulation 10% slough without odor and moderate serous drng (drainage).
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 6 cm x 3 cm x 0.5 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are rolled under/thickened and wound healing status is stable. Under comments documents, No discomfort during dressing change. This was completed by a registered nurse.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5.5 cm x 2.5 cm x 1 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 4.0 cm tunnel from 11 o'clock, 12 o'clock 2.5 cm tunnel. undermining from 1-4 o'clock and 9-10 o'clock 1.5. This assessment was completed by the facility wound nurse.
The nurses note dated 9/29/22 documents, Coccyx wound assessed, measured and dressing changed. Wound appears clean with 100% granulation tissue. No odor noted and drainage is moderate serous. Pt (patient) tolerated dressing change well. To continue with current dressing change orders and off-loading. Hospice updated to needed wound supplies per facility policy.
On 9/29/22 the treatment for the wound bed and for the dressing covering the coccyx remained the same except the order included: if Maxorb Ag was not available Aquacel rope may be used.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5.5 cm x 2.5 cm x 1.2 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 4.0 cm tunnel from 11 o'clock, 3.0 cm at 12 o'clock. Undermining 2.0 cm from 1-3 o'clock and 9-10 o'clock.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5 cm x 2.5 cm x 1.2 cm. Exudate is moderate serous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is improving. Under comments documents 4.0 cm tunnel from 11 o'clock, 2.5 cm at 12 o'clock, 3.0 cm at 9 o'clock. Undermining 1.5 cm from 1-2 o'clock and 10 o'clock.
The physician progress note dated 10/19/22 under HPI (history present illness) documents, Reviewed care with RN Care Coordinator (name.) This is my second visit with her. I had seen her 2 months ago on rehab. She had the right femur fracture. She says it is not really pain but discomfort. She has a (sic) ulcer on her coccyx that (RN Care Coordinator name) says measures 5 x 2.5 x 1.2 in depth she says it is stage IV (4).
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5 cm x 2.5 cm x 1.2 cm. Exudate is moderate serosanguineous, there is no wound odor, wound bed is 100% granulation, wound edges/margins are well defined wound edges and wound healing status is stable. Under comments documents 4.0 cm tunnel at 11 o'clock, 2.0 cm at 12 o'clock, 2.0 cm at 9 o'clock. Undermining 1.5 cm from 1-2 o'clock and 10 o'clock.
The nurses note dated 10/20/22 documents Wound to coccyx area assessed and measured. Wound continues to be stable with no s/sx of infection. Wound is not draining as heavily, tx (treatment) changed from BID to daily. To continue with offloading interventions.
On 10/20/22 the coccyx pressure injury treatment was changed to cleanse area with wound cleanser, gently pack tunneled area with Maxorb AG (may use plain Maxorb or Aquacel/Aquacel ag rope if Maxorb ag supply is not available) apply hydrogel to wound and cover with bordered foam sacral dressing daily and prn (as needed).
The nurses note dated 10/23/22 documents Coccyx wound draining into incontinence pad and somewhat odorous. Contact isolation implemented. Surveyor noted there was no physician notification. Surveyor noted there were no details of a consultation despite indicating the wound was somewhat odorous.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5 cm x 2.5 cm. There is no depth documented. Exudate is moderate seropurulent, there is no wound odor, wound bed is 100% epithelial tissue, wound edges/margins are Edge attached to base and wound healing status is stable. Surveyor noted this assessment was completed by a Licensed Practical Nurse and there is no indication the physician or nurse practitioner were consulted with.
The wound assessment dated [DATE] documents stage as Stage IV (4), measurements are 5.5 cm x 2 cm x 0.5 cm. Exudate is heavy seropurulent, there is a slight foul odor, wound bed is 100% granulation tissue, wound edges/margins are well defined wound edges and wound healing status is declining. Under comments documents, There is a 1.5 cm x 1.0 cm eschar area to left side of coccyx wound that is communicated with undermining of wound.
The nurses note dated 10/27/22 documents Coccyx wound has increased drainage and has a cloudy tan serosanguineous drainage with increased erythema to peri-wound, slight odor noted. Dressing tx (treatment) changed from daily to BID (twice daily). NP (Nurse Practitioner) updated per facility policy to frequency to dressing changes and of wound observations. Wound culture and sensitivity requested and obtained.
On 10/27/22 the coccyx pressure injury treatment was changed to Cleanse area with wound cleanser, gently pack tunneled area with Maxorb AG (may use plain Maxorb or Aquacel/Aquacel ag rope if Maxorb ag supply is not available) apply hydrogel to wound and cover with bordered foam sacral dressing BID & PRN.
The physician orders dated 10/27/22 documents coccyx wound culture and sensitivity.
The nurses note dated 10/30/22 documents Updated (name,) APNP, on culture with sensitivity. Received order for Doxycycline for 10 days and Florastor for 14 days. POA (power of attorney) for HC (healthcare), here to visit and updated on new orders.
The lab report dated 10/30/22 documents Staphylococcus aureus, methicillin resistant.
The nurses note dated 10/31/22 documents, Resident remains on report to monitor r/t (related to) NOR (new order received) for ABT (antibiotic)/Doxycycline for MRSA (methicillin-resistant staphylococcus aureus) of coccyx wound. No adverse effects noted from ABT use. Skin is warm, dry and color is WNL (within normal limits)/pink. Resident denies pain/discomfort to coccyx area, dressing remains C/D/I. (clean/dry/intact) Temp (temperature) is 97.6
The physician order dated 10/31/22 documents: Add Amoxicillin 500 mg BID x 7 days dx (diagnosis) infection to coccyx wound.
On 10/31/22 at 9:15 a.m., Surveyor observed R9 sitting in a wheelchair with a cushion in her wheelchair and being wheeled by activities staff to a Halloween activity.
On 10/31/22 at 10:35 a.m., Surveyor asked R9 if she has any open areas. R9 replied, yes on my butt but they take care of it. Surveyor asked R9 how she received this area. R9 replied I don't know.
On 10/31/22 at 2:24 p.m., Surveyor observed R9 sitting in a wheelchair in her room with a male visitor sitting next to her.
On 11/1/22 at 7:07 a.m., Surveyor observed R9 sitting in a wheelchair at a dining room table. R9 has a cushion in her chair. R9 was inquiring why she was up so early and indicated she wanted to go back to bed. After observing R9, Surveyor went to R9's room to see if there was a cushion in R9's personal type recliner. Surveyor observed a cushion in the personal type recliner with the cover indicating Invacare floair, and noted there is not a specialized mattress on R9's bed.
On 11/1/22 at 8:31 a.m., Surveyor spoke to CNA (Certified Nursing Assistant) F regarding R9. CNA F informed Surveyor R9 was up early, had a little breakfast, and wanted to go back to bed. Surveyor observed R9 in bed on her right side with her eyes closed. The call light is within R9's reach and R9's heels are not being offloaded.
On 11/1/22 at 9:58 a.m., Surveyor observed R9 in bed on her left side.
On 11/1/22 at 9:59 a.m., Surveyor asked CNA F what time R9 would be getting out of bed. CNA F informed Surveyor they got her up a few minutes ago, took R9 to the toilet, and R9 wanted to go back to bed. CNA F informed Surveyor R9 is usually a one assist for transfers but they had to use a lift to transfer her so R9 must not be feeling good.
On 11/1/22 at 10:46 a.m., Surveyor asked RN/CC (Registered Nurse)/Care Coordinator C if there is a wound team at the Facility. RN/CC C informed Surveyor there is a wound nurse (name) who comes in on Thursdays. Surv
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 refer 1 (R62) of 1 residents reviewed for a Level II PASARR (Preadmis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not refer 1 (R62) of 1 residents reviewed for a Level II PASARR (Preadmission Screen and Resident Review) whom was found to have a newly diagnosed mental illness and prescribed psychotropic medication used to treat the symptoms of the mental illness.
On 4/13/2022 R62 was diagnosed with Generalized Anxiety Disorder and started to receive Depakote and the Zoloft. On 5/11/2022 R62 was diagnosed with Psychotic disorder with delusions due to known physiological condition. On 5/11/2022 R62 began receiving Abilify to treat symptoms. On 7/7/2022 R62 was diagnosed with Alzheimer's disease with late onset and on 10/19/2022 R62 was diagnosed with Dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbances. The facility had not completed a new level 1 or 2 PASARR screen for R62 until Surveyor inquired about the screen.
Findings include:
The facility policy, entitled Preadmission Screening and Resident Review (PASRR) (sic), dated 7/17/2017, states:
I. Purpose: To identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement.
D. If the resident has a change in condition, which affects BIMS (exception: a physical change such as a stroke will not warrant a PASRR) or changes in psychotropic medication, a new PASRR will be completed.
R62 was admitted to the facility on [DATE], and had diagnoses that include displaced fracture of medial condyle of left tibia, subsequent encounter for closed fracture with routine healing, unspecified fracture of lower end of left femur, subsequent encounter for closed fracture with routine healing and chronic kidney disease stage 3 unspecified.
R62's admission MDS (Minimum Data Set) dated, 2/22/2022, indicated that R62's BIMS (Brief Interview of Mental Status) was scored at a 4 indicating severe cognitive impairment. Section I, Active Diagnoses, does not have any check marks for anxiety, psychotic disorder, or Alzheimer's. No check marks under Psychiatric/Mood Disorders or Neurological sections. Section N, Medications, documents no antidepressants or antianxiety medication given over the past 7 days.
R62's Quarterly MDS (Minimum Data Set) dated, 8/25/2022, documents a BIMS score of 3, indicating R62 is severely cognitively impaired. Section I, Active Diagnoses documents Psychotic disorder with delusions due to known physiological condition and anxiety. Section N, Medications, documents antidepressants were given in the past 7 days.
On 10/31/2022, Surveyor review R62's current medications on the Medication Administration Record (MAR). The MAR documents that R62 is currently receiving Depakote 125mg BID (two times per day), Depakote 250mg HS (at bedtime), and Zoloft 100mg HS (at bedtime).
Review of R62's medical record documents an initial PASARR Level I screen dated 2/14/2022. This document that R62 is not suspected of having a serious mental illness or developmental disability. It also documents that R62 has not received psychotropic medications to treat symptoms or behaviors of a major mental disorder in the past six months.
Surveyor could not locate any additional PASARR Level I or Level II screens in R62's chart. Surveyor notes that a new PASARR Level I screen should have been completed when R62 received a diagnosis of Generalized Anxiety Disorder on 4/13/2022 and started to receive Depakote and the Zoloft. Additionally, on 5/11/2022 R62 was diagnosed with Psychotic disorder with delusions due to known physiological condition and began receiving Abilify to treat symptoms. On 7/7/2022 R62 was diagnosed with Alzheimer's disease with late onset and on 10/19/2022 R62 was diagnosed with Dementia in other diseases classified elsewhere, unspecified severity with other behavioral disturbances.
On 11/01/2022, at 9:45 AM, Surveyor requested copies of R62's PASARRS from DON-B.
On 11/01/2022, at 2:24 PM, facility provided a copy of the admission PASARR Level I screen dated 2/14/2022. The DON-B then provided another PASARR Level I screen dated 11/1/2022 and stated that the SW-E (Social Worker) submitted another PASARR Level I today.
On 11/02/2022, at 9:48 AM, Surveyor interviewed SW-E and asked who is responsible to complete PASARR screens. SW-E informed the Surveyor that upon admission typically the director of Social Services completes the admission PASARR and then the unit SW would be responsible to complete any future PASARR screens should a resident need one. Surveyor asked SW-E what would happen if after admission a resident presented with a mental illness and/or stated receiving psychotic medication for behavior or symptoms of a mental illness. SW-E informed Surveyor that a new Level I screen would be completed. Surveyor informed SW-E that a PASARR Level I screen could not be located in R62's chart after receiving new psychotic/mood disorder diagnoses and psychotropic medication which started back in April 2022. SW-E was not sure why one was not completed for R62. SW-E stated, for sure she should have had a new Level I completed when the psychotropic medication was started. SW-E then stated that she did complete a new PASARR Level I screen earlier today.
On 11/2/2022, DON-B, was notified on the concern regarding R62 and missing PASARR screens.
No further information was provided as to why the facility did not refer R62 for a Level II PASARR Screen prior to 11/1/2022.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, the Facility did not ensure that 1 (R29) out of 5 residents reviewed for unnecessary medication received behavior monitoring based on their targeted behaviors.
R...
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Based on record review and interview, the Facility did not ensure that 1 (R29) out of 5 residents reviewed for unnecessary medication received behavior monitoring based on their targeted behaviors.
R29 was administered Lexapro 10 mg (milligrams) without behavior monitoring completed for the continued use of this medication.
Findings include:
R29's diagnoses includes late onset Alzheimer's disease and depressive disorder.
The quarterly MDS (minimum data set) with an assessment reference date of 9/20/22 documents R29's short & long term memory is ok and is severely impaired for cognitive skills for daily decision making. R29 has a total mood score of 9 which indicates mild depression. R29 is coded as having received an antidepressant in the last 7 days.
The physician order dated 8/10/22 documents Lexapro (escitalopram oxalate) tablet 10 mg (milligrams); amt (amount): 10 mg: oral once a day PM (evening).
The psych consult dated 8/10/22 documents occasionally mildly teary if she remembers husband's death. Recommendations were to add Lexapro.
The psych consult dated 9/14/22 documents no change in treatment.
During R29's record review Surveyor was unable to locate behavior monitoring for R29's Lexapro.
On 11/1/22 at 10:40 a.m. Surveyor informed RN/CC (Registered Nurse/Care Coordinator)-C Surveyor noted R29 is receiving Lexapro 10 mg once daily. Surveyor informed RN/CC-C Surveyor was unable to locate behavior monitoring for use of this medication. RN/CC-C informed Surveyor behavior monitoring is not in the electronic record and is on paper. RN/CC-C informed Surveyor they do not monitor behavior at this time but would look to see if there is any behavior monitoring.
On 11/2/22 at 8:17 a.m. RN/CC-C informed Surveyor R29 was initially started on Lexapro 10 mg on 12/8/21 and in January 2022 Lexapro was increased to 20 mg as R29 stated she had feelings of depression. RN/CC-C explained R29 has had a long slow gradual decline and started hospice on June 8th. RN/CC-C informed Surveyor in March most of R29's oral medications including Lexapro were discontinued as she would close her mouth and turn her head. RN/CC-C informed Surveyor Lexapro 10 mg was started on 8/10/22 as she was crying out in bed and had more anxiety in relation to pain. Surveyor asked RN/CC-C if there is any behavior monitoring for R29. RN/CC-C replied no. Surveyor asked whether there should be behavior monitoring for R29. RN/CC-C replied that's debatable. RN/CC-C informed Surveyor when [name of] psych NP (nurse practitioner) comes in she will speak with her and the staff. RN/CC-C informed Surveyor the CNA's (Certified Nursing Assistants) on days are regular staff. Surveyor informed RN/CC-C R29's behavior for being placed on Lexapro should be monitored to help determine if the medication should continue, be decreased or discontinued. RN/CC-C informed Surveyor she can get a behavior monitoring sheet going.
On 11/2/22 at approximately 3:50 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.
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
- • Grade B+ (80/100). Above average facility, better than most options in Wisconsin.
- • No fines on record. Clean compliance history, better than most Wisconsin facilities.
- • 31% turnover. Below Wisconsin's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 8 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Shorehaven Hlth & Rehab Ctr's CMS Rating?
CMS assigns SHOREHAVEN HLTH & REHAB CTR an overall rating of 5 out of 5 stars, which is considered much 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 Shorehaven Hlth & Rehab Ctr Staffed?
CMS rates SHOREHAVEN HLTH & REHAB CTR's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 31%, compared to the Wisconsin average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Shorehaven Hlth & Rehab Ctr?
State health inspectors documented 8 deficiencies at SHOREHAVEN HLTH & REHAB CTR during 2022 to 2025. These included: 2 that caused actual resident harm and 6 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Shorehaven Hlth & Rehab Ctr?
SHOREHAVEN HLTH & REHAB CTR 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 88 certified beds and approximately 77 residents (about 88% occupancy), it is a smaller facility located in OCONOMOWOC, Wisconsin.
How Does Shorehaven Hlth & Rehab Ctr Compare to Other Wisconsin Nursing Homes?
Compared to the 100 nursing homes in Wisconsin, SHOREHAVEN HLTH & REHAB CTR's overall rating (5 stars) is above the state average of 3.0, staff turnover (31%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Shorehaven Hlth & Rehab Ctr?
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 Shorehaven Hlth & Rehab Ctr Safe?
Based on CMS inspection data, SHOREHAVEN HLTH & REHAB CTR 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 5-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 Shorehaven Hlth & Rehab Ctr Stick Around?
SHOREHAVEN HLTH & REHAB CTR has a staff turnover rate of 31%, 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 Shorehaven Hlth & Rehab Ctr Ever Fined?
SHOREHAVEN HLTH & REHAB CTR has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Shorehaven Hlth & Rehab Ctr on Any Federal Watch List?
SHOREHAVEN HLTH & REHAB CTR 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.