Prescott Nursing and Rehab Community

In the surveyor’s words

From the most serious findings on record at Prescott Nursing and Rehab Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF693Apr 7, 2025

  Based on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) reviewed. (R33) R33 was not given enteral feeding nutrition as ordered; instead R33 received twice as much as ordered resulting in vomiting and aspiration, requiring suctioning and transfer to hospital on [DATE] where R33 expired on [DATE]. The facility's failure to properly monitor, assess, and correctly follow physician (MD) orders and treatments for enteral feeding resulted in resident receiving twice as much enteral feeding as ordered and created a finding of Immediate Jeopardy (IJ) that began on [DATE]. […]

• Immediate jeopardy, isolatedF580Aug 24, 2021

  Based on interview and record review the facility did not consult with the resident's physician when the resident had a significant change in condition for 2 of 3 residents (R) reviewed (R6, R5). *R6 had a decrease in oxygen saturation and change in mental status and the physician was not consulted and medical intervention was not obtained. This resulted in the resident developing [CONDITION(S)], and the resident expired. Failure to consult with a physician when a resident had a significant change in condition created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on [DATE] at 3:30 PM. […]

• Immediate jeopardy, isolatedF678Aug 24, 2021

  Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation) for 1 of 1 residents (R) reviewed, in accordance with the resident's treatment options (R6). R6's treatment options at time of admission on [DATE] stated Full Resuscitation. On [DATE], nursing staff called 911 due to R6's low oxygen saturation and unresponsiveness. Paramedic's note stated R6 was pulseless upon their arrival, and CPR was started by paramedics. The paramedic note stated staff stated R6 may have been pulseless for 5 to 10 minutes. Nursing staff did not initiate CPR prior to the arrival of the paramedics. […]

• Immediate jeopardy, isolatedF695Aug 24, 2021

  Based on record review and interview, the facility did not ensure that 1 of 1 residents (R) reviewed received appropriate respiratory care, consistent with professional standards of practice (Wisconsin Nurse Practice Act), during a significant change in medical condition (R6). R6 had a significant change in medical condition with a drop in oxygen saturation to the low 80s. R6 had ongoing change in mental status despite improved oxygen saturations. The facility did not provide ongoing assessment, planning, intervention, or evaluation throughout the day. R6 developed respiratory failure and died . The facility's failure to recognize the significant change in condition, and provide appropriate respiratory care, created a finding of immediate jeopardy that began on [DATE]. […]

• Actual harm, isolatedF684Aug 24, 2021

  Based on record review and interview, the facility did not ensure that a resident (R) with bleeding and drainage from a surgical wound received the necessary care and treatment in accordance with professional standards of practice for 1 of 1 residents reviewed, (R5.) R5 had a fall on 06/18/21 and was evaluated in the emergency department (ED). R5 had bloody drainage noted from a right hip surgical dressing after the fall. The bleeding and drainage continued from the surgical dressing after R5 returned from the ED. The facility did not assess the surgical incision or dressing to determine if a change in treatment was needed. […]