Complete Care at Manitowoc LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Manitowoc LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 27, 2023

  Based on staff and resident interview and record review, the facility failed to protect residents' rights to be free from sexual abuse when they determined 2 cognitively impaired Residents (R) (R1 and R5) of 5 sampled residents engaged in a sexual act despite interviews that indicated R1 and R5 did not want a sexual relationship with each other. The facility was aware R1 had a history of exposing R1's genitals when R1 was admitted to the facility on [DATE]. Staff was also aware that approximately two months prior to 9/5/23 (date unknown), staff reported R1 and R5 were observed in R1's room with R1's brief and pants down, and R1's genitals exposed. The facility provided an undated and incomplete investigation that indicated R5 was helping R1 with R1's pants. […]

• No harm, potential for more than minimal, widespreadF804May 18, 2022

  Based on observation, Resident (R) interviews, resident representative interviews, staff interviews, and record review, the facility did not ensure food was at a palatable temperature. This practice had the potential to affect all 109 residents. Facility served hot held foods below hot holding temperature requirement (135 degrees Fahrenheit (F)) which Surveyor felt and residents described as lukewarm to cold in mouth. Findings include: Observations On 5/16/22 at 11:30 AM, Surveyor observed meal service in 200 unit dining area. Surveyor observed a plate warmer located in hallway near dining was not plugged in. 200 unit kitchenette steam table did not have water in the water wells. Dietary Cook (DC) I placed steam table trays in the empty steam table water wells. […]

• No harm, potential for more than minimal, widespreadF809May 18, 2022

  Based on observation, Resident (R) interviews, staff interview, and record review, the facility did not serve meals consistently at regular mealtimes. This had the potential to affect all 109 residents. Meals were served over one and a half hours after posted time. Findings include: Record Review Meals times by unit provided to survey team: Unit Breakfast Lunch Supper 200 7:45 AM 12:00 PM 5:45 PM 300 7:00 AM 11:30 AM 5:00 PM 400 7:45 AM 12:00 PM 5:45 PM 500 7:30 AM 11:30 AM 5:30 PM 600 7:00 AM 11:30 AM 5:00 PM 700 7:00 AM 11:30 PM 5:00 PM Observations 200 Unit On 5/16/22 at 11:27 AM, Surveyor began continuous meal service observation when thermal carts containing lunch meal arrive at 200 unit kitchenette. […]

• No harm, potential for more than minimal, widespreadF812May 18, 2022

  Based on observation, staff interview, and record review, the facility did not ensure food was prepared in a sanitary manner. The practices had the potential to affect 109 residents. -Staff did not consistently document cooking and holding temperatures prior to meal service -Mixer was not clean -Dirty cleaning cloths were out on food preparation counter -Staff did not wait required amount of time before obtaining the temperature of food after microwave reheating Findings include: On 5/17/22 at 3:05 PM, Corporate Registered Dietician (RD) K informed Surveyor that the facility used the Food and Drug Administration (FDA) Food Code. 1. The FDA food code 2017 documents at 3-402.12: Records, Creation and Retention. […]

• No harm, potential for more than minimal, patternF812Jul 24, 2024

  Based on observation and staff interview, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 60 of 105 residents residing in the facility. On 7/23/24 and 7/24/24, beverages were not iced during meal service. The temperature of the milk at the end of meal service on 7/23/24 was 59 degrees Fahrenheit (F). Resident food was not heated in a microwave according to regulations or the facility's policy. Findings include: On 7/22/24 at 8:32 AM, Surveyor began an initial kitchen tour with Assistant Dietary Manager (ADM)-F who stated the facility follows the Wisconsin Food Code. […]