Inspection Results » Tomah Nursing and Rehab

Health Inspection on February 22, 2018 ^[1]

1. Pattern: Actual harm that is not immediate jeopardy

   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2018-03-27)

2. Isolated: Actual harm that is not immediate jeopardy

   • Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. (Corrected 2018-03-27)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-03-27)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-03-27)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-03-27)

3. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-03-27)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2018-03-27)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-03-27)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-03-27)

4. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (Corrected 2018-03-27)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2018-03-27)
   • Respond appropriately to all alleged violations. (Corrected 2018-03-27)

5. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-03-27)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-03-27)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2018-03-27)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-03-27)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-03-27)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-03-27)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-03-27)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-03-27)
   • Provide and implement an infection prevention and control program. (Corrected 2018-03-27)
   • Assess the resident when there is a significant change in condition (Corrected 2018-03-27)