Menominee Health Services

In the surveyor’s words

From the most serious findings on record at Menominee Health Services, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 25, 2021

  Based on observation, interview and record review, the facility failed to maintain infection control program practices to prevent continued spread of COVID-19 (a highly transmissible [MEDICAL CONDITION] infection) by failing to: 1. Ensure effective screening and prevention of staff from working with signs and symptoms consistent with COVID-19. 2. Ensure appropriate standards of infection control practice were maintained for respiratory equipment. 3. Ensure appropriate use of Personal Protective Equipment (PPE) in resident care areas. 4. Ensure proper infection control practice in performing routine glucometer testing. 5. Prevent contamination of multidose medication packaging during administration. 6. […]

• No harm, potential for more than minimal, widespreadF801Apr 3, 2024

  Based on interview and record review the facility failed to employ a full time dietitian, certified dietary manager or a certified food service manager to manage the food service department. Findings include: (All reported times are in EDT) On 4/2/24 at approximately 8:15 AM, an interview was conducted with Kitchen Manager (KM) A about her certification as a dietary manager. KM A stated she had not completed the Certified Dietary Manager's (CDM) course work, nor had begun or signed up for the course. Additionally, KM A stated she had no other food service training likened to a Certified Food Manager, Serve Safe certification or other. […]

• No harm, potential for more than minimal, widespreadF802Apr 3, 2024

  Based on observation, interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill to carry out the functions of the food and nutrition services. Findings include: (All reported times in EDT) On 4/2/24 at approximately 8:15 AM, an interview was conducted with Kitchen Manager (KM) A about her certification as a dietary manager. KM A stated she had not completed the Certified Dietary Manager's (CDM) course work, nor had begun or signed up for the course. Additionally, KM A stated she had no other food service training likened to a Certified Food Manager, Serve Safe certification or other. […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2024

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: (All reported times are in EDT) On 4/2/24 at approximately 7:30 AM, during the initial observation period in the kitchen, a 2 gallon Lexan container was observed in the Traulsen refrigerator. A label on the top identified the contents as Spag sauce and had a date of 3/31 then UB (use by) or Freeze by 4/3. An interview with Kitchen Manager (KM) A was conducted at this time and learned the cook responsible for putting the product had not documented the cooling process. KM A stated she was working on making a form for staff to follow. […]

• No harm, potential for more than minimal, widespreadF880Apr 3, 2024

  Based on observation, Interview, and record review, the facility failed to perform process and outcome surveillance for all 34 facility residents. This deficient practice possibly contributed to an outbreak of Covid-19 resulting in the infection of 15 residents. Findings include: (All times are recorded in Eastern Daylight Time) On 4/2/24 at 7:18 AM, the facility door was observed to have a sign indicating there was a current Covid-19 outbreak in the facility. The Director of Nursing (DON) stated the Covid-19 outbreak included 15 residents and had begun with one Covid-19 positive resident on 3/28/24. On 4/3/24 at approximately 9:00 AM, the DON (who was also functioning as the facility Infection Preventionist [IP]) was interviewed on the infection control practices of the building. […]