American Lutheran Home-Menomonie

In the surveyor’s words

From the most serious findings on record at American Lutheran Home-Menomonie, in the surveyor’s own words.

• Actual harm, isolatedF580Jun 20, 2024

  Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition post procedure. This occurred for 1 of 4 residents (R15) reviewed for physician notification and consultation. R15 presented with new symptoms of lethargy and fever post ureteral stent placement. Staff did not immediately notify R15's provider of this occurrence resulting in actual harm when R15 was found unresponsive and admitted to the hospital 12/07/23 - 12/13/23, with a diagnosis of sepsis (a serious condition in which the body responds improperly to an infection) secondary to acute (sudden onset) pyelonephritis (a type of urinary tract infection where one or both kidneys become infected), acute hypoxic… […]

• No harm, potential for more than minimal, widespreadF880May 17, 2023

  Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 28 residents in the building. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system. - Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. […]

• No harm, potential for more than minimal, widespreadF908May 17, 2023

  Based on observation, interview and record review, the facility did not have a system in place to maintain the scale inhibitor for the Rational oven per manufacturer's guidelines. This has the potential to affect all 28 residents in the facility. The facility had no system to ensure changing of the scale inhibitor filter, causing malfunction of the Rational oven. [NAME] repairs, the facility did not implement a system to ensure routine maintenance was completed for the oven. This is evidenced by: On 05/17/23 at 10:40 AM, Surveyor asked the Culinary Supervisor (CS) F about the scale inhibitor filter for the Rational oven (kitchen equipment that cooks the food in varying ways such as steaming). Surveyor asked CS F when the scale inhibitor filter was last changed. […]

• No harm, potential for more than minimal, patternF909Apr 13, 2022

  Based on observation, interview and record review, the facility did not perform regular inspections of all bed frames, mattresses, and bed rails as a regular part of maintenance program to identify areas of possible entrapment for 5 of 5 residents (R) with bed rails. (R11, R18, R20, R5, and R22) Findings include: Example 1 R11 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes with peripheral [CONDITION(S)], and chronic pain. R11's Minimum Data Set (MDS) assessment identified R11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R11 was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF628Aug 27, 2025

  Based on record review and interview, the facility did not notify the Ombudsman of a resident who was transferred from the facility to a hospital for 1 of 3 residents (R) (R1) reviewed. The facility policy, titled Notification of Changes, dated 03/32/2017, states, The facility will notify the proper parties when changes occur. Under Section 5(a)(1) states in part, The facility will send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman program when there is an appeal to the discharge decision. R1 was admitted to the facility on [DATE]. On 06/27/25, R1 had a change in condition and was transferred to the hospital. A Bedhold and Notice of Transfer form was provided to R1. […]