Inspection Reports for Oconto Health and Rehabilitation Center

The facility was found deficient in ensuring proper physician orders and cleaning for CPAP machine use, administering pneumococcal and COVID-19 vaccines timely and with proper orders, and maintaining safe equipment operation, specifically lint trap cleaning in dryers. Deficiencies were noted with minimal harm or potential for actual harm affecting a few to some residents.

The visit was complaint-related involving allegations of failure to notify physicians, inadequate grievance handling, abuse allegations not reported or investigated, unqualified staff providing care, and infection control breaches.

The facility was found deficient in multiple areas including failure to notify a physician of a resident's worsening skin condition, inadequate grievance documentation and follow-up, failure to report and thoroughly investigate an allegation of abuse, unqualified staff performing personal care and feeding duties, and failure to adhere to infection prevention and control protocols including gown use and hand hygiene during care.

The complaint investigation found substantiated issues including failure to notify physician and Guardian of medication refusals, inadequate nutritional and hydration care, and pharmaceutical service deficiencies including medication errors.

The facility failed to notify a resident's physician and Guardian about multiple medication refusals, did not provide adequate treatment and services to prevent weight loss and dehydration for two residents, and did not provide pharmaceutical services to meet the needs of two residents, including a medication error involving administration of incorrect medication.

The complaint investigation found that the facility did not allow a resident to manage personal funds due to lack of guardian cooperation, failed to provide appropriate care to maintain range of motion for a resident, and did not consistently monitor nutrition and hydration intake for another resident, with substantiation of these issues.

The facility failed to allow a resident to set up a petty cash or Resident Fund Management Service account due to guardian non-responsiveness, did not provide interventions to prevent worsening of a resident's hand contracture, and inconsistently monitored nutrition and hydration intake for another resident, resulting in weight loss and missing documentation.

The complaint investigation focused on resident R1 who repeatedly exited the facility without signing out or notifying staff, despite cognitive impairment and safety risks. The facility failed to implement adequate supervision and safety measures, leading to multiple incidents where R1 was found by police in dangerous situations. The facility also failed to provide timely medically-related social services and guardianship assistance. Immediate Jeopardy was identified on 7/30/24 and removed on 8/28/24 after corrective actions.

The facility failed to provide adequate supervision and safety interventions for R1, who had impaired cognitive function and repeatedly left the facility unsupervised, resulting in multiple police interventions and hospitalizations. The facility's failure created an Immediate Jeopardy situation that was removed after corrective actions were implemented, but deficiencies remained at a lower severity level. Additionally, the facility did not provide appropriate medically-related social services, including timely psychiatric follow-up and guardianship assistance.

The facility failed to ensure proper implementation of its abuse policy for 2 of 8 employees reviewed, including incomplete out-of-state background checks for the Director of Nursing and incomplete Background Information Disclosure forms for a Laundry Aide.

The facility was found deficient in multiple areas including inaccurate self-administration medication assessments and physician orders, incomplete PASRR screening, incomplete and inaccurate care plans for residents, failure to provide necessary nail care, incomplete medical record documentation, and inadequate infection prevention and control practices including improper hand hygiene, storage of medical supplies, and sanitation of equipment.

The facility failed to ensure that 3 sampled residents had call lights within reach, and did not ensure accurate medication administration for 1 resident, including failure to administer hydrocortisone as ordered and improper disposal of medication by staff.

The complaint investigation found that grievances reported by residents R5 and R6 about CNA-C's rough care and neglect were not properly documented or resolved. R5 had severely impaired cognition and an activated Power of Attorney, while R6 had moderate cognitive impairment and a Guardian. Interviews with the Director of Nursing and Nursing Home Administrator confirmed inadequate documentation and ongoing corrective actions with CNA-C.

The facility did not properly document or resolve grievances for two residents who reported issues with CNA-C not changing clothing and ignoring soiled conditions. The grievance file lacked documentation for these concerns, and interviews revealed that education was provided to CNA-C, who was on a last chance status due to these issues.

The facility failed to provide pharmaceutical services that ensured timely administration of medications for three residents, with multiple instances of medications administered outside the acceptable time frame. Additionally, a Lidocaine patch was not applied as ordered to one resident. The Director of Nursing confirmed these findings.

The complaint investigation revealed that on 10/2/23, resident R2 sexually abused resident R1 by inappropriately touching and attempting to remove R1's brief. Staff initially did not take the allegation seriously, delaying intervention. The facility initiated 1:1 supervision for R2 and moved R2 to a different room. Telehealth psychiatric services and social worker support were offered to R1. Staff education on abuse reporting was completed. The immediate jeopardy was removed on 10/2/23 at 8:00 PM.

The facility failed to ensure a safe environment free from abuse, specifically failing to supervise a resident who sexually abused another resident, creating immediate jeopardy to resident health or safety. The immediate jeopardy was identified on 10/2/2023 and removed the same day by implementing 1:1 supervision for the alleged abuser, relocating the resident, and providing additional support and education to staff and residents.

The facility was found deficient in ensuring resident privacy during care, maintaining a safe and home-like environment due to uneven floors and damaged ceilings, providing appropriate care for range of motion, ensuring nurse aide competency, timely medication administration, monitoring high-risk medications, and maintaining sanitary food preparation and storage conditions.

The complaint involved an allegation of misappropriation of property for Resident R3. The allegation was substantiated as the facility did not report it to law enforcement as required by policy.

The facility failed to report an allegation of misappropriation of property involving Resident R3 to law enforcement, despite reporting it to the State Agency. The facility's policy requires reporting such allegations to law enforcement, but this was not followed.