Inspection Reports for Clove Lakes Healthcare and Rehabilitation Center

The facility failed to ensure that one resident with a known mushroom allergy did not receive mushrooms on their meal tray, resulting in an allergic reaction that required immediate medical treatment. The investigation concluded there was no substantial evidence of an allergic reaction, but the facility's policies and procedures related to allergy documentation and meal ticket updates were found deficient.

The facility failed to develop and implement a comprehensive person-centered care plan for one resident with macerated skin around a stoma and a rash on the abdomen. Despite physician orders and nursing documentation, no care plan was created or updated to address these skin impairments.

One isolated Level 2 deficiency for developing and implementing a comprehensive care plan, corrected as of April 5, 2025.

Two isolated Level 2 deficiencies related to abuse and neglect and reporting of alleged violations, both corrected as of December 20, 2024.

The visit was complaint-related involving allegations of physical abuse of Resident #4 by Certified Nursing Assistant #2 and failure to report sexual abuse allegations involving Resident #2 and Resident #3. The investigation was inconclusive for abuse in the physical abuse case and found no reasonable suspicion in the sexual abuse allegation.

The facility failed to protect a resident from physical abuse by a nursing assistant and failed to develop and implement policies for timely reporting of suspected abuse, including sexual abuse allegations. Investigations were inconclusive for abuse but identified policy deficiencies and staff actions leading to minimal harm or potential harm.

The facility was found deficient in ensuring residents were fully informed in a language they understood, developing and implementing comprehensive care plans for residents' needs, timely review and revision of care plans, and ensuring medications provided by the pharmacy were not expired.

Multiple isolated Level 2 deficiencies related to quality of care, assessments, care planning, pharmacy services, and life safety code issues including sprinkler system installation, all corrected by December 2024.

The facility was found deficient in multiple areas including inaccurate Minimum Data Set assessments failing to reflect residents' psychiatric behaviors, failure to coordinate assessments with the PASARR program for residents with serious mental disorders, failure to provide medications as ordered including seizure and thyroid medications, and failure to notify physicians when medications were unavailable. Several residents exhibited behavioral and medication administration issues that were not properly addressed.

The facility was found deficient in multiple areas including improper use of physical restraints without proper orders or care plans, failure to update comprehensive care plans after falls, inadequate supervision to prevent falls, oxygen therapy provided without physician orders, lack of timely physician review of care and labs, failure to act on pharmacist recommendations for lab testing, expired food found in storage, and lapses in infection control practices related to COVID-19 precautions.

Numerous isolated and patterned Level 2 deficiencies in quality of care, medication management, infection control, resident rights, and life safety code issues including electrical systems and emergency lighting, all corrected as of January 2023.

The facility was found deficient in multiple areas including failure to provide timely and proper Notice of Medicare Non-Coverage to residents, inaccurate resident assessments, inadequate pain management during wound care, improper medication storage and labeling, and failure to maintain infection control practices such as preventing oxygen tubing from touching the floor.