Trempealeau Cty HCC Imd

In the surveyor’s words

From the most serious findings on record at Trempealeau Cty HCC Imd, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 8, 2023

  Based on observation and staff interview, the facility did not follow proper food handling practice. This practice had the potential to affect all 34 residents residing in the facility. Staff did not properly seal/cover and date open food items in the cold storage. Findings include: The facility policy entitled, Storage of Food and Supplies, revised December 7, 2020, which states in part, .Cover, label and date unused portions and open packages . On 11/06/23 at 7:34 AM, Surveyor completed the initial tour of the kitchen with Cook E. Cook E took Surveyor into refrigerated storage. There was a gallon of white milk opened and over half full on the shelf in the refrigerator. Surveyor noted there was no date written on the milk container as to when it was opened. […]

• No harm, potential for more than minimal, widespreadF851Nov 8, 2023

  Based on interview and record review, the facility did not ensure the mandatory submission of staffing data based on payroll data was completed. This had the ability to affect all 34 residents residing in the facility. Payroll Based Journal (PBJ) data was not submitted by the facility since the last annual survey. Findings include: PBJ staffing data reports generated quarterly indicated the facility triggered for Failed to submit PBJ data for the fiscal year quarter 3 2023 (April 1 - June 30). Review of the past year PBJ reports show no reporting was completed by this facility. On 11/06/23 at 1:30 PM, Surveyor spoke with Nursing Home Administrator (NHA) A and Director of Finances (DF) D concerning the PBJ. […]

• No harm, potential for more than minimal, widespreadF880Nov 8, 2023

  Based on interview and record review, the facility did not maintain an infection prevention and control program according to professional standards of practice having the potential to affect all 34 residents residing in the facility at the time of survey. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: Include a comprehensive assessment of the facility's water system to identify all locations where Legionella could grow and spread. Maintain acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met. […]

• No harm, potential for more than minimal, isolatedF761Mar 10, 2026

  Based on observation, interview, and record review, the facility failed to secure controlled substances in a locked container separate from containers for any non-controlled medications, and to linit access to authorized personnel consistent with state or federal requirements and professional standards of practice for all 31 residents in the facility.Surveyor observed a medication refrigerator inside the locked medication room that did not have a lock in place securing entry to medications. Surveyor observed a box of liquid oral lorazepam and a vial for IV injection of lorazepam. […]

• No harm, potential for more than minimal, isolatedF880Mar 10, 2026

  Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R)(R5) observed during cares.Certified Nursing Assistant (CNA) C and CNA D did not use Enhanced Barrier Precautions (EBP) when providing direct care for R5.This is evidenced by:Facility policy, titled Enhanced Barrier Precautions, with a reviewed date of 01/06/26, states in part: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high… […]