Oconto Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at Oconto Health and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF692Mar 7, 2022

  Based on observation, interview, and record review, the facility did not ensure residents maintained acceptable parameters of nutritional status for 5 Residents (R) (R13, R17, R32, R24, and R37) of 8 reviewed for nutrition concerns. R17 sustained a severe weight loss of 25.51% from 09/06/21 to 02/05/22. The facility did not implement Dietician-D's recommendations for monitoring nutritional status. Additionally, the facility did not have a systemic process to record, monitor, and assess R17's intake when R17 developed a stage IV pressure injury. R13 sustained a severe weight loss of 16.43% from 08/11/21 to 02/17/22. The facility did not properly assess, evaluate, and address R13's nutritional status. […]

• Immediate jeopardy, isolatedF689Sep 3, 2024

  Based on staff interview and record review, the facility did not provide adequate supervision to prevent accidents for 1 resident (R) (R1) of 3 sampled residents. On 6/8/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to a location in another city that was 37 miles from the facility. On 6/14/24, R1 exited the facility without signing out and told staff when found that R1 intended to walk to the same location. On 7/30/24, R1 left the facility and was found by police walking on a county highway that was 1.4 miles from the facility. On 8/6/24, R1 exited the facility without signing out and was found by police after 9:00 PM walking into on-coming traffic on an interstate highway off-ramp that was over 1.5 miles from the facility. […]

• Immediate jeopardy, isolatedF600Oct 24, 2023

  Based on staff and resident interview and record review, the facility did not ensure a safe environment that was free from abuse for 1 Resident (R) (R1) of 3 sampled residents. On 10/2/23 at approximately 7:45 PM, R1 told Certified Nursing Assistant (CNA)-C that R2 had inappropriately touched R1 and had tried to get into R1's brief. CNA-C indicated the incident didn't happen and no action was taken. Approximately fifteen minutes later at 8:00 PM, staff heard R1 yell. Staff entered R1's closed door and observed R2, who was completely disrobed, on top of R1 and inappropriately touching R1. The facility's failure to supervise a resident who allegedly sexually abused another resident created a finding of immediate jeopardy that began on 10/2/23 at approximately 7:45 PM. […]

• Actual harm, isolatedF686Mar 7, 2022

  Based on observation, record review, and staff interview, the facility did not ensure each resident received necessary treatment to prevent pressure injuries from developing for 2 Residents (R) (R8 and R17) of 4 sampled residents reviewed for pressure injuries. Facility staff did not properly assess R17's deep tissue injury that developed around 12/15/21 until 01/26/22. R17's care plan was not updated to include current pressure injuries and interventions and the treatment record shows missing treatments. […]

• No harm, potential for more than minimal, widespreadF880Jul 3, 2024

  Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 2 (Human Resources (HR)-G and Certified Nursing Assistant (CNA)-F) of 3 staff reviewed for infection surveillance and 4 residents (R) (R13, R32, R23, and R189) of 14 sampled residents. This practice had the potential to affect all 35 residents residing in the facility. The facility did not complete details of a staff illness line list used for infection surveillance for HR-G and CNA-F. During an observation on 7/2/24, CNA-I did not perform appropriate hand hygiene during the provision of care for R13. […]