Sauk Co Health Care Center

In the surveyor’s words

From the most serious findings on record at Sauk Co Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 17, 2026

  Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 2 sampled residents (R46). R46 had a history of Foley catheter obstruction resulting in UTI (Urinary Tract Infection) and sepsis. On [DATE] - [DATE], staff observed and documented that R46 had decreased urine output, including no output on the NOC (overnight) shift on [DATE]. There is no evidence of provider notification of the overall decreased output and no evidence of increased monitoring or assessments by facility staff. On [DATE], R46 was transferred to the hospital and admitted to the ICU with due to an occluded Foley catheter, UTI, and septic shock. […]

• Immediate jeopardy, isolatedF686Apr 7, 2025

  Based on interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 of 3 residents (R) reviewed for pressure injuries (R19). R19 was at risk for developing pressure injuries (PI) related to decreased mobility, bilateral above knee amputation, and radiation therapy. R19 developed a facility-acquired stage 3 PI. The facility did not identify or stage this as a PI but considered it a chronic wound, identifying the root cause was related to friction and shearing from the use of a slide board transfer. The facility continued to use the slide board transfer until after R19 had a EpiFix flap procedure to heal the PI. […]

• Immediate jeopardy, isolatedF684Oct 30, 2024

  Based on interview and record review, the facility did not ensure that each resident received, and the facility provided, care and services consistent with professional standards of practice (N6. Wisconsin Nurse Practice Act) for 1 of 5 residents (R4) reviewed for change of condition. R4 presented with a change of condition including decreased appetite (even her favorite foods), abdominal pain, fatigue, nausea, and vomiting. The facility failed to complete a GI (Gastrointestinal)/abdominal assessment and failed to notify R4's physician with R4's complaints of abdominal pain. […]

• Immediate jeopardy, isolatedF689Oct 30, 2024

  Based on interview and record review, the facility failed to ensure each resident (R) received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for falls. On 9/2/24, R1 was in the shower room when CNA D (Certified Nursing Assistant) attempted to remove R1's incontinent product from under her while she was sitting in the shower chair. This caused R1 to begin to fall. CNA D and CNA E assisted R1 to the floor. When a nurse had not shown up for 15 minutes, CNA D & CNA E assisted R1 off of the floor prior to a nurse assessing R1 for any type of injury. From the fall incident on 9/2/24, R1 sustained a fracture to her right tib/fib. On 10/4/24, R1 had an x-ray completed that showed an angulated and displaced left femur fracture. […]

• Immediate jeopardy, isolatedF686May 1, 2024

  Based on observation, interview, and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 1 sampled residents (R12) out of a total sample of 17 residents reviewed. R12 developed a pressure injury in the facility. Over time, this pressure injury developed an odor, grew in size, and was noted to have an increase in drainage. The facility did not update R12's Medical Doctor (MD) with these changes. Surveyor observed R12 calling out, striking, and wincing in pain during wound care. […]