Stevens Point Health Services

In the surveyor’s words

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

• Actual harm, isolatedF686Nov 6, 2024

  Based on observation, staff and resident interview, and record review, the facility did not ensure 2 residents (R) (R1 and R3) of 3 sampled residents received the necessary care and services to prevent and heal pressure injuries. R1 was admitted to the facility following a fall with fractures and had bilateral splints to the lower extremities. The splints were not removed for skin checks and R1 developed an unstageable deep tissue injury (DTI) on the right heel. In addition, R1 had a pressure injury on the sacrum that was allegedly present upon admission on 10/1/24. Treatment was not initiated until 10/4/24 and air mattress was not ordered until 10/11/24. R3 was admitted to the facility on [DATE] with a pressure injury on the left heel. […]

• Actual harm, isolatedF686Jun 21, 2023

  Based on interviews and record review, the facility did not ensure that residents received care consistent with professional standards of practice to prevent Pressure Injuries (PI) from developing for 1 of 3 sampled residents (R). (R2). On 6/3/23, a new pressure area was identifiied on R2's coccyx. The faciltiy did not assess, call the MD, and add any new interventions to promote healing according to facility policy and standards of practice. R2's pressure injury was identified by the wound clinic on 6/7/23 and the facility recieved orders. The facility did not implement interventions on the care plan until 6/20/23, or initiate weekly assessements that would include weekly measurements, description, and staging of the pressure injury. […]

• No harm, potential for more than minimal, widespreadF801May 8, 2024

  Based on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This practice had the potential to affect all 42 residents residing in the facility. Dietary Manager (DM)-H did not complete an approved dietary manager or food service manager certification course or other related education. Findings include: On 5/6/24 at 9:53 AM, Surveyor interviewed DM-H who indicated DM-H just started as a cook at the facility. […]

• No harm, potential for more than minimal, widespreadF812May 8, 2024

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 42 residents residing in the facility. Staff did not complete hand hygiene after washing dishes and prior to touching ready to eat food. The counter was not in clean condition when staff cut vegetables. The microwave was not in clean condition and the mixer was not covered. Staff did not maintain unit refrigerator and freezer temperature logs. Open items in the walk-in cooler and dry storage area did not contain open dates. Findings include: On 5/6/24 at 9:48 AM, Surveyor began an initial kitchen tour with Dietary Manager (DM)-H who stated the facility follows the Wisconsin Food Code. […]

• No harm, potential for more than minimal, widespreadF882May 8, 2024

  Based on staff interview and record review, the facility did not ensure the designated Infection Preventionist (IP) completed infection prevention and control training and was employed at least part-time in the facility. This practice had the potential to affect all 42 residents residing in the facility. The facility's designated IP did not work in the facility at least part-time. Findings include: The Centers for Medicare & Medicaid Services (CMS) memo QSO-22-19-NH, last revised 6/29/22, indicates: In 2016, CMS overhauled the Requirements for Participation for Long-Term Care (LTC) facilities (i.e., nursing homes) which was implemented in three phases: .Phase 3 (11/28/19) regulations require nursing homes to have an Infection Preventionist who has specialized training onsite at least… […]