West Bend Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at West Bend Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 20, 2021

  Based on staff interviews, chart reviews and policy review the facility failed to provide needed care or services by not notifying the resident's physician of acute decline in health status for one of three residents reviewed, (Resident #1) which resulted in immediate jeopardy to resident health and safety. Resident #1 had an emesis event on 9/30/20 at 7:30 pm and was visibly not feeling well. The resident was diaphoretic, pale, moaning, and breathing heavy. The resident had no bowel sounds at that time and was complaining about pain in her lower abdomen which was tender to the touch. Resident #1 was given Tylenol, a suppository, and an injection of [MEDICATION NAME] for comfort. The resident became lethargic but able to answer questions per her baseline. […]

• No harm, potential for more than minimal, patternF725Jan 12, 2024

  Based on resident interview, resident council minutes and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes for 2 of 2 residents, (Resident #4 and #5). The facility identified a census of 40 residents. Findings include: During an interview on 1/5/24 at 8:49 a.m. a friend of Resident #4 indicated while she participated in a Zoom meeting with the resident on the computer she timed the resident's call light as on for 25 minutes. The resident had also told her she timed her call light on for 20 minutes up to 30 minutes at times. During an interview on 1/11/24 at 12:35 p.m. […]

• No harm, potential for more than minimal, patternF657Dec 29, 2022

  Based on observations, clinical record review, staff interviews, the facility failed to revise a Care Plan for 4 of 4 residents reviewed (Residents #5, #31, #20, and #30). The facility reported a census of 38. Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #5 was independent with bed mobility, transfers, walking and toileting. Resident #5 used a walker and a wheelchair. […]

• No harm, potential for more than minimal, patternF801Dec 29, 2022

  Based on facility record review and staff interview, the facility failed to ensure there was qualified staff with the appropriate competencies and skill sets to carry out food and nutrition services. Findings include: During an interview with the Administrator on 12/27/22 at 10:22 a.m.,she stated they had a Certified Dietary Manager (CDM) hired and that he was going to be starting 12/28/22. She stated that in the meantime, the assistant cook was fulfilling the requirements of the position until the newly hired CDM started. The Administrator stated that the assistant cook was CMD certified. […]

• No harm, potential for more than minimal, patternF812Dec 29, 2022

  Based on observations and staff interviews, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, to store dishes upside down to prevent contamination, failed to maintain dishwasher sanitizing parameters, failed to have properly cleaned equipment, and failed to have a Certified Dietary Manager (CDM) overseeing the kitchen. The facility census was 38 residents. Findings include: An initial tour of the kitchen conducted on [DATE] at 9:05 a.m., revealed the following items stored in the refrigerator ready for service: Plastic bottle of tartar sauce with no open date on bottle. Jar of pickles with no open date on jar. Generic plastic squeeze bottle with syrupy substance not labeled, no open date. […]