Inspection Reports for
Ingleside Manor
407 N EIGHTH ST, MOUNT HOREB, WI, 53572
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
25 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
443% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Oct 13, 2025
Visit Reason
Annual recertification survey of Ingleside Manor nursing home to assess compliance with federal regulations and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident rights, advanced directives, safe environment, abuse reporting, care and treatment, pressure injury prevention and care, catheter care, nutrition, medication administration, infection control, hospice coordination, and immunizations. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (15)
F 0565: Facility failed to ensure grievances discussed in Resident Council meetings were promptly acted upon, specifically regarding unanswered facility phones affecting multiple residents.
F 0578: Facility did not ensure residents' rights to request, refuse, or discontinue treatment and to formulate advance directives for 5 of 18 residents reviewed.
F 0584: Facility failed to provide a safe, clean, comfortable, and homelike environment, including shower room disrepair and a broken chair rail posing safety hazards.
F 0609: Facility failed to timely report suspected abuse involving resident R42 to the state agency within required two hours.
F 0684: Facility failed to provide appropriate treatment and care according to orders for 3 of 4 sampled residents and 1 supplemental resident, including incomplete wound care and lack of antibiotic treatment assessments.
F 0686: Facility failed to implement professional standards for pressure injury prevention and care for 2 residents, resulting in immediate jeopardy that was later removed but deficient practice continued.
F 0690: Facility failed to provide appropriate catheter care for resident R42, including reuse of unclean leg bags and lack of proper cleaning procedures.
F 0692: Facility failed to ensure resident R19 received adequate nutrition and protein intake consistent with his vegetarian diet, resulting in severe weight loss over 3 months.
F 0759: Facility had a medication error rate of 12.9% with errors including omitted medications, unauthorized medications, and incorrect dosages affecting 2 residents.
F 0761: Facility failed to store medications and biologicals in locked compartments and left expired medication on an unattended medication cart.
F 0806: Facility failed to provide food accommodating resident preferences and dietary needs, specifically for vegetarian resident R19 without appropriate protein alternatives.
F 0849: Facility failed to ensure hospice collaboration and communication for resident R28, lacking current hospice plan of care and designated staff to coordinate care.
F 0867: Facility failed to identify and correct quality deficiencies related to pressure injury care and prevention, lacking effective quality assurance and performance improvement activities.
F 0880: Facility failed to establish and maintain an infection prevention and control program, including inadequate water temperature monitoring and incomplete infection symptom surveillance.
F 0883: Facility failed to ensure residents R9 and R2 were offered pneumococcal vaccination as recommended by current guidelines.
Report Facts
Medication errors: 4
Weight loss: 16
Medication cart unattended time: 5
Pressure injury stage: 4
Residents with pressure injuries: 2
Residents reviewed for catheter care: 2
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ANHA C | Assistant Nursing Home Administrator | Named in findings related to phone issues, abuse reporting, and pressure injury care |
| DON B | Director of Nursing | Named in findings related to wound care, medication errors, catheter care, nutrition, infection control |
| RN N | Wound Care Nurse | Observed performing wound care with cross contamination and improper infection control |
| DM S | Dietary Manager | Interviewed regarding nutrition care and vegetarian diet accommodations |
| IP G | Infection Preventionist | Interviewed regarding infection control program deficiencies |
| NHA A | Nursing Home Administrator | Interviewed regarding hospice coordination and infection control |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Sep 15, 2025
Visit Reason
Annual survey inspection of Ingleside Manor nursing home to assess compliance with federal and state regulations related to resident rights, environment, care, medication administration, and behavioral health services.
Findings
The facility was found deficient in multiple areas including failure to honor resident rights related to dining preferences, inadequate housekeeping and cleanliness, failure to provide appropriate wound care and monitoring, lack of pressure injury prevention interventions, improper catheter care, failure to provide behavioral health care plans for substance use disorder and suicidal ideations, and multiple medication administration errors including omissions due to internet outages and delayed medication delivery.
Deficiencies (8)
F 0550: The facility did not ensure a resident's right to dignity and respect by failing to honor the resident's choice to eat in the dining room as documented in the care plan.
F 0584: The facility failed to maintain a safe, clean, and homelike environment for 4 residents, with observed dried substances, fecal matter on toilet surfaces, and infrequent housekeeping.
F 0684: The facility failed to provide appropriate wound care for a resident with a wound that increased in size and developed a foul odor without timely physician notification, resulting in hospital readmission for wound infection.
F 0686: The facility failed to provide pressure injury prevention interventions for a resident with a stage 2 pressure injury, including failure to use pressure-relieving devices as ordered.
F 0690: The facility failed to ensure appropriate catheter care as a resident's urinary catheter bag was observed resting on the floor contrary to policy.
F 0740: The facility failed to provide behavioral health care by not developing care plans for a resident with substance use disorder and another resident with a history of suicidal ideations and attempts.
F 0755: The facility failed to ensure pharmaceutical services met resident needs, with multiple medication administration errors including omissions due to internet outages and delayed medication delivery.
F 0760: The facility failed to ensure residents were free from significant medication errors, with two residents missing multiple doses of medications as ordered.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Medication doses missed: 2
Medication doses missed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Named in multiple findings related to wound care, pressure injury prevention, catheter care, behavioral health, and medication administration |
| LPN E | Licensed Practical Nurse | Named in medication administration delay and wound care interviews |
| ADON R | Assistant Director of Nursing | Named in medication administration interviews |
| NHA A | Nursing Home Administrator | Named in interviews related to medication administration and behavioral health care planning |
| SW Q | Social Worker | Named in interview regarding substance use disorder program |
| RN G | Registered Nurse | Named in medication administration and wound care interviews |
| LPN I | Licensed Practical Nurse | Named in wound care and behavioral health care planning interviews |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 13, 2025
Visit Reason
Routine inspection of Ingleside Manor nursing home to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant changes in resident condition, failure to report suspected medication misappropriation, inadequate assistance with activities of daily living, failure to provide treatment per orders, inadequate supervision for transfers, improper nutrition and hydration assistance, failure to ensure timely physician visits, medication errors including missed doses, infection control breaches, and ineffective pest control.
Deficiencies (11)
F 0580: The facility did not immediately notify and consult with a resident's physician when there was a significant change in condition for 1 of 10 residents reviewed.
F 0609: The facility did not ensure that all alleged violations involving misappropriation of resident property were reported immediately to the administrator for 1 allegation reviewed.
F 0677: The facility did not provide showering assistance for residents requiring assistance for 1 of 6 residents reviewed, resulting in missed weekly showers.
F 0684: The facility did not ensure residents received treatment and care in accordance with professional standards for 1 resident reviewed for bowel management.
F 0689: The facility did not ensure adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for falls.
F 0692: The facility did not ensure residents with G-Tubes were assisted with nutrition and hydration as ordered for 1 of 3 residents reviewed.
F 0712: The facility did not ensure residents were seen by a physician every 30 days for the first 90 days after admission and every 60 days thereafter for 1 of 15 residents reviewed.
F 0755: The facility did not provide pharmaceutical services to meet the needs of each resident, resulting in missed medications for 2 of 7 residents reviewed.
F 0760: The facility did not ensure residents were free from significant medication errors for 1 of 7 residents reviewed, including missed doses of buprenorphine-naloxone and cefazolin.
F 0880: The facility failed to implement an infection prevention and control program, with staff not performing proper hand hygiene during wound care and pericare for 2 residents.
F 0925: The facility did not ensure effective pest control in the dining area, hallways, and resident rooms, with multiple residents reporting fly infestations and observations of flies and ants in resident rooms.
Report Facts
Residents reviewed for notification of change in condition: 10
Residents reviewed for shower assistance: 6
Residents reviewed for bowel management: 1
Residents reviewed for falls supervision: 4
Residents reviewed for G-Tube nutrition: 3
Residents reviewed for physician visits: 15
Residents reviewed for medication administration: 7
Flies observed on resident: 6
Fly sticky strip observed: 1
Ant strips observed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN H | Licensed Practical Nurse | Named in medication error finding and notification failure |
| DON B | Director of Nursing | Named in multiple findings including notification failure, medication errors, and infection control |
| LPN C | Licensed Practical Nurse | Observed failing to perform hand hygiene during wound care |
| CNA N | Certified Nursing Assistant | Observed breaching infection control during pericare |
| RN I | Registered Nurse | Interviewed regarding medication administration and notification failures |
| MW E | Maintenance Worker | Interviewed regarding pest control issues |
| LPN L | Licensed Practical Nurse | Interviewed regarding medication administration process |
| RN/IP M | Registered Nurse/Infection Preventionist | Interviewed regarding infection control practices |
| NHA A | Nursing Home Administrator | Interviewed regarding reporting and medication processes |
| TD P | Therapy Director | Interviewed regarding resident transfer status |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jul 9, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and investigate specific complaints and incidents.
Findings
The facility was found deficient in multiple areas including failure to timely report and investigate alleged abuse and resident-to-resident altercations, inadequate supervision leading to elopement risk, failure to maintain and audit crash carts properly, failure to ensure residents with feeding tubes received appropriate care including proper order transcription and placement verification, incomplete medical records documentation, and lack of required staff performance evaluations and in-service education. The facility also failed to maintain a properly constituted Quality Assessment and Assurance Committee.
Deficiencies (9)
F0609: The facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for 3 of 5 reportable incidents.
F0610: The facility failed to thoroughly investigate and report results of resident-to-resident altercations involving residents R18, R2, and R19.
F0658: The facility failed to ensure crash carts were checked and supplies were available for basic life support for 2 crash carts affecting 34 residents.
F0689: The facility failed to provide adequate supervision and assistance devices to prevent accidents for residents at risk of elopement, smoking, suicidal ideations, and falls, resulting in immediate jeopardy that was later removed.
F0692: The facility failed to ensure a resident (R14) receiving assisted nutrition via enteral feeding maintained acceptable nutritional status due to transcription errors causing missed feedings for multiple days.
F0693: The facility failed to ensure residents with G-tubes (R15, R16, R17) had proper placement checks prior to feeding or medication administration and lacked nurse competency documentation.
F0730: The facility failed to complete annual performance evaluations and provide regular in-service education for 5 of 5 nurse aides reviewed.
F0842: The facility failed to maintain complete, accurate, and accessible medical records for residents including documentation of change of condition, suicidal ideations, and resident-to-resident altercations.
F0868: The facility failed to maintain a properly constituted Quality Assessment and Assurance Committee with required members and quarterly meetings.
Report Facts
Weight loss: 12
Crash carts: 2
Residents affected by crash cart issue: 34
Residents affected by elopement and supervision issues: 5
Nurse aides without annual evaluation: 5
Nurse aides lacking required annual education hours: 4
QAPI meetings missing Medical Director: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON D | Assistant Director of Nursing | Named in multiple findings including order entry error for tube feeding, supervision failures, and interview regarding nursing practices. |
| NHA A | Nursing Home Administrator | Named in interviews regarding supervision failures, QAPI meetings, and corrective actions. |
| LPN L | Licensed Practical Nurse | Named in interviews regarding resident care, tube feeding errors, and supervision. |
| RN J | Registered Nurse | Named in interviews regarding order verification and resident care. |
| CNA R | Certified Nursing Assistant | Named in interviews regarding resident supervision and elopement incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 10, 2025
Visit Reason
The inspection was conducted following a complaint regarding a resident's fall from a Hoyer lift during transfer, which resulted in a minor injury.
Complaint Details
The complaint investigation found that a resident fell from a Hoyer lift when the sling broke during transfer. The fall caused a minor injury with no intracranial abnormalities or fractures. Documentation of the fall was not completed in the EMR or incident reports. The former Director of Nursing and CNA involved confirmed the incident but were unsure about documentation. The Administrator at the time of the survey had no knowledge of the incident.
Findings
The facility failed to ensure resident safety during transfer when a sling broke causing the resident to fall and hit her head. Documentation related to the fall was missing, and the former Director of Nursing and CNA involved did not complete required incident reports or EMR documentation.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a resident falling from a Hoyer lift due to a sling breaking.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Named in the incident involving the resident fall from the Hoyer lift. |
| Director of Nursing 2 | Director of Nursing | Named in the incident involving the resident fall from the Hoyer lift and noted as former DON no longer employed. |
| RN2 | Registered Nurse | Interviewed regarding lack of documentation of the fall. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 14, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to timely notify hospice and family of a resident's change in condition, failure to timely report and investigate a resident-to-resident abuse allegation, and medication administration errors.
Complaint Details
The complaint investigation involved failure to timely notify hospice and family of a resident's change in condition, failure to timely report and investigate a resident-to-resident abuse allegation, and medication administration errors. The abuse allegation was substantiated as the facility failed to report within two hours and did not conduct a thorough investigation.
Findings
The facility failed to timely notify hospice and the resident's representative of a significant change in condition for one resident. The facility also failed to report a resident-to-resident abuse allegation within the required two-hour timeframe and did not thoroughly investigate the abuse allegation. Additionally, the facility failed to administer medications as scheduled, resulting in a medication error rate exceeding 5%.
Deficiencies (5)
F 0580: The facility failed to notify hospice and the resident's representative timely of a significant change in condition for 1 of 12 sampled residents, evidenced by a resident not eating or drinking for two to three days without timely notification.
F 0609: The facility failed to report a resident-to-resident abuse allegation involving 2 residents within the required two-hour timeframe.
F 0610: The facility failed to thoroughly investigate a resident-to-resident abuse allegation involving 2 residents by not interviewing all staff who may have had knowledge of the incident.
F 0755: The facility failed to administer medications as scheduled for 1 of 12 residents reviewed, with multiple late administrations and some doses not given due to unavailability.
F 0759: The facility did not ensure a medication error rate of 5% or less, with 18 errors out of 28 medication opportunities observed, affecting 3 of 4 residents observed for medication administration.
Report Facts
Residents sampled: 12
Medication errors observed: 18
Medication opportunities observed: 28
Medication error rate: 64.28
Residents affected by medication errors: 3
BIMS scores: 15
BIMS scores: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN6 | Registered Nurse | Named in relation to resident-to-resident abuse allegation reporting |
| RN3 | Registered Nurse | Administered medications late to resident R10 |
| RN4 | Registered Nurse | Reported medication supply issues and confirmed late medication administration |
| CNA1 | Certified Nurse Aide/Medication Aide | Administered medications late to resident R12 and reported being pulled to other tasks |
| CNA3 | Certified Nurse Aide | Reported resident-to-resident abuse allegation to nurse |
| CNA4 | Certified Nurse Aide | Reported resident-to-resident abuse allegation to nurse |
| CNA5 | Certified Nurse Aide | Interviewed regarding resident-to-resident abuse allegation |
| Assistant Administrator | Provided facility investigative file and interviews related to abuse allegation | |
| Director of Nursing | Director of Nursing | Provided statements on notification and medication administration expectations |
| Hospice RN1 | Registered Nurse | Provided hospice perspective on notification of resident condition change |
| FM1 | Family member reporting abuse allegation | |
| FM2 | Family member of resident with condition change |
Inspection Report
Routine
Deficiencies: 14
Date: Jul 11, 2024
Visit Reason
Routine inspection of Ingleside Manor nursing home to assess compliance with healthcare regulations including resident care, medication administration, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to ensure call lights were within reach for some residents, delayed physician notification for lab results, inadequate water temperature for showers, incomplete care plans for anticoagulant monitoring, failure to prevent hospitalization due to inadequate monitoring of acute condition changes, insufficient pressure ulcer prevention, poor nutritional monitoring, medication administration errors, unsanitary ice machine, improper garbage disposal, incomplete infection control policies, and failure to provide pneumococcal vaccine per guidelines.
Deficiencies (14)
F 0558: The facility failed to ensure call lights were within reach for 4 residents, making it difficult for them to call staff for assistance.
F 0580: The facility failed to immediately notify physicians for 2 residents when lab results required prompt attention, delaying treatment.
F 0584: The facility failed to provide comfortable water temperature for showers and sinks, causing residents to experience cold water.
F 0656: The facility failed to develop a comprehensive care plan addressing monitoring for side effects of Eliquis anticoagulant for 1 resident.
F 0684: The facility failed to provide appropriate treatment and monitoring for 1 resident with acute condition changes, resulting in hospitalization.
F 0686: The facility failed to implement a repositioning schedule for 1 resident at risk for pressure ulcers, contributing to skin breakdown.
F 0692: The facility failed to monitor meal intake and weight loss for 1 resident at nutritional risk, resulting in significant unaddressed weight loss.
F 0755: The facility failed to ensure 1 resident received scheduled medications on time, including missed nighttime medications.
F 0758: The facility failed to ensure individualized behavior monitoring for 1 resident on psychotropic medications, lacking targeted behavior assessments.
F 0759: The facility had medication errors including administering a medication at the wrong dose and time, and missed documentation of medication administration.
F 0812: The facility failed to properly clean and sanitize the ice machine, resulting in a black film inside the ice machine lid.
F 0814: The facility failed to properly dispose of garbage and refuse, resulting in unsanitary conditions around dumpsters.
F 0880: The facility failed to maintain an effective infection prevention and control program, including lack of staff illness line lists and outdated policies.
F 0883: The facility failed to offer pneumococcal vaccination to a resident when eligible and did not document education or declination.
Report Facts
Medication errors: 6
Weight loss: 26
Medication error rate: 8
Pressure ulcer risk score: 15
Meal intake charting: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN Q | Registered Nurse | Discovered missed nighttime medications for resident R18 and documented medication error. |
| RN D | Registered Nurse | Administered medication incorrectly to resident R46 by breaking tablet and giving wrong dose. |
| DON B | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, care plan issues, and monitoring failures. |
| ADON/IP C | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control deficiencies and vaccination tracking. |
| DM F | Dietary Manager | Interviewed regarding nutritional monitoring and ice machine cleaning responsibilities. |
| RN O | Registered Nurse | Observed administering medication despite elevated blood pressure and corrected error. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate supervision and fall prevention for residents, specifically focusing on two residents (R3 and R1) with concerns about falls and smoking safety.
Complaint Details
The investigation was complaint-driven focusing on falls and smoking safety. The complaint was substantiated with findings of actual harm to residents due to inadequate supervision and safety measures.
Findings
The facility failed to ensure adequate supervision and fall prevention for resident R3, who experienced multiple falls with fractures without proper root cause analysis or care plan updates. Resident R1 was found to have smoking materials, including an e-cigarette, in his room despite known noncompliance and moderate risk assessment.
Deficiencies (2)
F 0689: The facility did not ensure adequate supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed for falls. Resident R3 experienced multiple falls with fractures and the facility failed to assess or identify root causes or update care plans accordingly.
Resident R1 had smoking materials in his room despite the facility being aware of his noncompliance with smoking policies and risk assessment indicating moderate problem with smoking in unauthorized areas.
Report Facts
Number of falls experienced by R3 since March 2023: 9
Fall risk assessment scores for R3: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP D | Nurse Practitioner | Interviewed regarding STAT imaging orders and fall assessments for resident R3. |
| DON B | Director of Nursing | Interviewed regarding facility policies on STAT orders and RN assessments after falls. |
| LPN C | Licensed Practical Nurse | Documented and interviewed about resident R3's fall and pain assessments. |
| NHA A | Nursing Home Administrator | Interviewed about resident R1's smoking privileges and awareness of e-cigarette in room. |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 30, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including medication self-administration, resident rights, care planning, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure safe self-administration of medications, inadequate follow-up on resident grievances, incomplete care planning for oral hygiene and fall prevention, inconsistent snack provision, unsafe food storage and sanitation practices, and deficiencies in infection prevention and control during a COVID-19 outbreak.
Deficiencies (9)
F 0554: The facility did not ensure self-administration of medications was clinically appropriate for a resident who was observed with unsupervised medications at bedside without an assessment or order.
F 0565: The facility failed to provide feedback or timely follow-up on concerns voiced by residents at Resident Council meetings for multiple residents.
F 0580: The facility did not notify a resident's activated power of attorney promptly of significant changes in the resident's condition and failed to follow physician orders for bladder scans.
F 0585: The facility did not ensure grievances were promptly resolved or properly documented for residents reporting missing personal items and other concerns.
F 0677: The facility failed to provide adequate oral care to a dependent resident and did not have a comprehensive care plan addressing oral hygiene.
F 0689: The facility failed to update and personalize fall prevention care plans and did not educate staff on interventions for a resident with a history of falls and fractures.
F 0809: The facility did not consistently offer snacks at bedtime despite a 15-hour gap between dinner and breakfast, affecting most residents.
F 0812: The facility failed to maintain a safe and sanitary food service environment including dirty equipment, ice buildup in freezer, dented cans in circulation, and inadequate dishwasher temperatures.
F 0880: The facility failed to implement an effective infection prevention and control program during a COVID-19 outbreak, including incomplete resident testing, inadequate staff screening, and inaccurate outbreak line lists.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 56
Residents affected: 56
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in medication self-administration finding |
| DON B | Director of Nursing | Interviewed regarding medication self-administration, bladder scan orders, and infection control |
| AD J | Activity Director | Named in Resident Council grievance follow-up finding |
| SW K | Social Worker / Grievance Official | Named in grievance resolution deficiency |
| CNA L | Certified Nursing Assistant | Interviewed regarding oral care provision |
| NHA A | Nursing Home Administrator | Interviewed regarding fall prevention and snack provision |
| CNA F | Certified Nursing Assistant | Interviewed regarding fall prevention interventions |
| RN G | Registered Nurse | Interviewed regarding fall prevention interventions |
| DM H | Dietary Manager | Interviewed regarding food safety and snack provision |
| RD I | Registered Dietician | Interviewed regarding snack provision |
| IP D | Infection Preventionist | Interviewed regarding COVID-19 outbreak and infection control |
| RN E | Registered Nurse | Named in COVID-19 outbreak staff screening |
| CNA M | Certified Nursing Assistant | Named in COVID-19 outbreak staff screening |
| RN N | Registered Nurse | Named in COVID-19 outbreak staff screening |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's activated Power of Attorney for Health Care (APOAHC) about significant changes in the resident's condition and changes in physician orders.
Complaint Details
The complaint investigation found that the facility did not notify the resident's APOAHC promptly about changes in the resident's condition and physician orders. The APOAHC reported communication problems and disagreement with discontinued orders. The facility staff prioritized physician orders but did not update the APOAHC as required.
Findings
The facility failed to promptly notify the resident's APOAHC of changes in physician orders and did not consistently follow physician orders for bladder scans and toileting. Documentation was incomplete, and communication with the APOAHC was inadequate.
Deficiencies (1)
F 0580: The facility did not promptly notify the resident's activated Power of Attorney for Health Care of changes in physician orders and failed to implement bladder scan and toileting orders as prescribed. Documentation of bladder scan results was incomplete, and communication with the APOAHC was insufficient.
Report Facts
Residents Affected: 1
Bladder scan completion: 2
Bladder scan completion: 0
Bladder scan completion: 3
Bladder scan completion: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding changes to resident R18's bladder scan orders and communication with APOAHC. |
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