Door County Memorial Hospital SNF

In the surveyor’s words

From the most serious findings on record at Door County Memorial Hospital SNF, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF610Jul 2, 2025

  Based on staff and resident interview and record review, the facility did not ensure allegations of abuse and an injury of unknown origin were thoroughly investigated for 4 residents (R) (R1, R2, R10, and R7) of 8 sampled residents. R1 reported an allegation of abuse by Certified Nursing Assistant (CNA)-G on 4/10/25. The facility did not remove CNA-G from resident care pending an investigation or provide staff education regarding appropriate behavior with residents and professional boundaries. In addition, a skin assessment was not completed until two days after the allegation was reported.R2's family reported an allegation of abuse that involved CNA-L. The facility did not provide staff education on the facility's abuse policy or education on appropriate behavior during resident care. […]

• No harm, potential for more than minimal, patternF880Feb 19, 2025

  Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R28 and R17) of 2 residents. This practice had the potential to affect more than 4 of the the 31 residents who resided in the facility. Staff did not ensure the facility's infection surveillance line list was current and up-to-date for R28 and R17. Staff did not ensure a laundry cart was covered to prevent contamination of clean linens and did not ensure clean and dirty areas were not subject to cross-contamination in the laundry room. […]

• No harm, potential for more than minimal, patternF610Jan 4, 2024

  Based on staff interview and record review, the facility did not thoroughly investigate an allegation of abuse for 1 Resident (R) (R18) of 1 resident prior to allowing the accused staff member to continue providing resident care. This had the potential to affect 14 residents. On 12/28/23 at 6:30 PM, an allegation of verbal abuse involving Certified Nursing Assistant (CNA)-C and R18 was reported to Nursing Home Administrator (NHA)-A. CNA-C was not removed from resident care areas per the facility's policy pending the results of the investigation. […]

• No harm, potential for more than minimal, isolatedF689Apr 28, 2026

  Based on observation, staff and resident interview, and record review, the facility did not ensure appropriate fall interventions were implemented for 2 residents (R) (R5 and R2) of 2 sampled residents.R5 had multiple falls from January to April 2026. Interventions to prevent falls or reduce injury from falls were not consistently implemented or care planned. R2 fell out of bed after a bolstered air mattress (a specialized mattress with raised, air-filled side chambers that create a protective barrier to prevent roll-outs and falls) was broken and replaced with a mattress without bolstered edges. […]

• No harm, potential for more than minimal, isolatedF580Jul 2, 2025

  Based on staff interview and record review, the facility did not ensure an activated Power of Attorney for Healthcare (POAHC) and physician were notified timely of a change in condition for 1 resident (R) (R7) of 12 sampled residents.R7 sustained a skin tear of unknown origin on 6/7/25. R7's physician and POAHC were not notified of the injury until 6/10/25. Findings include:The facility's Notification of Changes in Condition or Status of Resident policy, revised 7/31/24, indicates: To assure that each resident receives prompt, high quality nursing service and medical care .Changes in a resident's condition or treatment are immediately shared with the resident and/or resident representative, according to their authority, and reported to the attending physician .1. […]