Alden Meadow Park Hcc
ALDEN MEADOW PARK HCC in CLINTON, WI — inspection on January 30, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
would do if she found a resident to be pulseless and non-breathing. LPN C stated she would check for
DNR, she would check the paperwork on file to prove it was a signed DNR.
Together Surveyor and
On [DATE] at 11:43 AM, Surveyor interviewed RN D (Registered Nurse) and asked what she would do if she found a resident to be pulseless and non-breathing. RN D stated she would initiate CPR and call for a rapid response.
Surveyor asked RN D where she would find a resident's code status. RN D replied that she would look on the resident's banner in the EHR.
Together Surveyor and RN D reviewed R312's banner in the EHR, which stated Full Code.
On [DATE] at 11:48 AM, Surveyor interviewed RN E and asked what she would do if she found a resident to be pulseless and non-breathing. RN E stated she would check the resident's breathing and start CPR.
Surveyor asked RN E where she would find a resident's code status. RN E replied that she would look in the resident's chart in the EHR or at the nurse's desk.
Together Surveyor and RN E reviewed R312's banner in the EHR, which stated Full Code.
Surveyor asked RN E if she found R312 to be pulseless and non-breathing, would she provide CPR. RN E stated yes, she would provide R312 with CPR.
On [DATE] at 12:01 PM, Surveyor interviewed DON B (Director of Nursing) and asked her if she expected the nursing staff to check a resident's code status before starting CPR. DON B replied yes, that was her expectation.
Surveyor asked DON B if R312 was CPR or DNR. DON B reviewed the EHR and stated R312 was a Full Code and would receive CPR in the event of an emergency.
Surveyor reviewed with DON B the copy of the DNR form signed by R312 on [DATE] that had been scanned into his EHR. DON B stated that R312 would be a DNR as of today.
On [DATE] at 12:12 PM, Surveyor interviewed DSS F (Director of Social Services) and asked her if R312 was a Full Code or a DNR. DSS checked in R312's EHR and stated he was a Full Code.
Surveyor asked DSS F if the EHR banner, physician orders, signed DNR form, and EHR code status should all match. DSS F stated they should all be the same.
Surveyor asked DSS F if all of them should accurately reflect the resident's advance directive wishes. DSS F stated yes, everything in the resident's EHR should be accurate.
Surveyor reviewed R312's DNR form signed on [DATE] by R312 and scanned into the resident's EHR, as well as the banner that indicated Full Code. DSS F indicated she would change that immediately.
On [DATE] at 1:49 PM, NHA A (Nursing Home Administrator) supplied a copy of R312's revised order, which states in part: .NO CPR: Do Not Attempt Resuscitation (DNAR) . as well as a screen shot of R312's banner in the EHR, which now indicated: (Advance Directives): NO CPR. Do Not Attempt Resuscitation (DNAR).
The electronic health record (EHR) did not accurately reflect R312's wishes to be a DNR.
525508 01/30/2025
Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525
stated that she had been in R33's room to administer medications but had not noticed her trays.
consider that a homelike environment.
On 1/29/25 at 1:59 PM, Surveyor interviewed CNA H and asked her if she would consider it a homelike environment if a resident had breakfast and lunch trays still sitting in their room with dirty dishes and food on them. CNA H stated no, she did consider it homelike, and she didn't let dirty dishes sit around in her own home. CNA H stated she had been in R33's room but had not noticed the trays sitting there.
On 1/29/25 at 2:09 PM, Surveyor observed LPN C remove R33's breakfast tray and CNA H remove R33's lunch tray.
On 1/29/25 at 3:00 PM, Surveyor interviewed R33 and asked her if she considered it a homelike environment to have her breakfast and lunch trays sitting in her room with dirty dishes and food on them. R33 indicated that she did not think that was a homelike environment and stated that it upsets her when they do that. R33 stated she would be embarrassed if visitors came to see her and there was nowhere to sit because the chair had a tray with dirty dishes on it.
On 1/30/25 at 3:19 PM, Surveyor interviewed ADON I (Assistant Director of Nursing) and asked what her expectations would be for removing trays from resident rooms after meals. ADON I replied that R33 takes a long time to eat, and requests that her meal trays be kept in her room for longer.
Surveyor asked ADON I if she would expect a breakfast tray to still be in the room after 2:00 PM. ADON I replied no, that was too long for the breakfast tray to still be in her room.
Surveyor asked ADON I if she expected the residents to have a homelike environment, including free of clutter and dirty dishes.
ADON I indicated yes, that was her expectation.
525508 01/30/2025
Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525
comfortable.
Surveyor asked ADON I how often the staff should be assisting R33 with repositioning.
acceptable for R33 to be sitting in the same position in her wheelchair for 6 hours. ADON I indicated
Cross Reference: F-F688, F-F697
525508 01/30/2025
Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525
ADON I if she would expect the care plan interventions and physician orders to be followed in walking
525508 01/30/2025
Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525
confirmed that R33 has rheumatoid arthritis which would indicate pain.
appropriate pain management interventions and strategies. R33's has diagnoses that indicate pain.
documentation shows that staff are often not walking with her. R33 indicates that she has pain daily and that staff are not assessing or treating her pain.
Cross Reference F-F677 and F-F688
(FR); 07/13 (SA); 07/14 (SU); 07/15 (MO); 07/16 (TU); 07/17 (WE); 07/18 (TH); 07/19 (FR); 07/20
(SU); 07/29 (MO); 07/30 (TU); 07/31 (WE) 08/01 (TH); 08/02 (FR); 08/03 (SA); 08/04 (SU); 08/05 (MO); 08/06 (TU); 08/07 (WE); 08/08 (TH); 08/09 (FR); 08/10 (SA); 08/11 (SU); 08/12 (MO); 08/13 (TU); 08/14 (WE); 08/15 (TH); 08/16 (FR); 08/17 (SA); 08/18 (SU); 08/19 (MO); 08/20 (TU); 08/21 (WE); 08/22 (TH); 08/23 (FR); 08/24 (SA); 08/25 (SU); 08/26 (MO); 08/27 (TU); 08/28 (WE); 08/29 (TH); 08/30 (FR); 08/31 (SA) 09/01 (SU); 09/02 (MO); 09/03 (TU); 09/04 (WE); 09/05 (TH); 09/06 (FR); 09/07 (SA); 09/08 (SU); 09/09 (MO); 09/10 (TU); 09/11 (WE); 09/12 (TH); 09/13 (FR); 09/14 (SA); 09/15 (SU); 09/16 (MO); 09/17 (TU); 09/18 (WE); 09/19 (TH); 09/20 (FR); 09/21 (SA); 09/22 (SU); 09/23 (MO); 09/24 (TU); 09/25 (WE); 09/26 (TH); 09/27 (FR); 09/28 (SA); 09/29 (SU); 09/30 (MO) Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 1/1/24-3/31/24. (It is important to note this report would have showed the hours that were reported to CMS.) On 1/28/25 at 11:00 AM, NHA A (Nursing Home Administrator) indicated the Corporate Office staff submit the PBJ data to CMS. NHA A indicated the data was submitted inaccurately and because of this the facility's star rating dropped to a 1 out of 5. NHA A indicated the facility used a computer system to store PBJ data and the company went under.
Then the Corporate Office staff had to manually enter the data into the CMS website. NHA A explained the Corporate Office staff entered page one data and clicked to page two.
She did not press the save button.
Then page two data was entered, and the Corporate Office Staff clicked to page 3 without pressing save.
After page three data was entered the Corporate Office staff pressed submit thinking all three pages would be submitted, but only page three was submitted. NHA A indicated page one and page two populated with all zeroes while page three data read correctly. NHA A indicated after submitting the data the page locks and there is no way to correct or add an addendum. NHA A indicated she understands the requirements set by CMS and the information was not reported accurately.
525508 01/30/2025
Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525
The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for four fiscal year quarters for excessively low weekend staffing, triggered one fiscal year quarter for failure to have licensed nursing coverage 24 hours a day, and triggered for one fiscal year quarter for failure to have RN (registered nurse) hours each day
Evidenced by:
According to https://www.cms. gov/medicare/quality/nursing-home-improvement/staffing-data-submissionExample the Centers for Medicare & Medicaid Services (CMS) has long identified staffing as one of the vital components of a nursing home's ability to provide quality care. CMS has utilized staffing data for a myriad of purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes .
Therefore, CMS has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ).
This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy .
The first mandatory reporting period began July 1,2016 .
The deadlines for each reporting period are as follows: Fiscal Quarter 1-October 1- December 31 due February 14, Fiscal Quarter 2- January 1- March 31 due May 15, Fiscal Quarter 3- April 1 - June 30 due August 14, Fiscal Quarter 4- July- September 30 due November 14 .
November 1, 2017, CMS began posting a public use file containing PBJ staffing data submitted by long term care facilities.
The file includes the hours nursing staff are paid to work each day, for each facility.
The categories of nursing staff include director of nursing, registered nurses with administrative duties, registered nurses, licensed practical nurses with administrative duties, licensed practical nurses, certified nurse aides, medication aides, and nurse aides in training.
The file also includes a facility's census for each day within the quarter as calculated using the minimum data set (MDS) submission.
Example 1:
CMS's PBJ Staffing Data Report, for fiscal year quarter 1 2024 (October 1 - December 31), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey .
Excessively Low Weekend Staffing: Triggered - Submitted Weekend Staffing data is excessively low .
Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility .
Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 10/1/2024-12/31/24. (It is important to note this report would have showed the hours that were reported to CMS.)
Example 2:
525508
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525508 B.
Wing 01/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525
The facility failed to adequately assess R33's pain or provide non-pharmacologic interventions to treat her pain.
This is evidenced by:
The facility policy titled, Pain Management, dated 4/19/12 states, in part: Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity.
Procedure: 1.
Residents shall be assessed for pain and his or her manner of expressing pain upon admission, re-admission, and annually . 3.
Residents will be assessed for chronic pain or persistent pain (a pain state that continues for a prolonged period of time or recurs more than intermittently for months) when the symptoms present themselves .
Plan of Care: For any resident with orders for scheduled pain management, staff will initiate an interdisciplinary plan of care based on the initial assessment and the development of pain relieving strategies.
The plan will include both pharmacological and complementary interventions.
Documentation: Document interventions and responses to pain management in the medical record as appropriate (i.e. medication administration record, treatment record, nursing progress notes, etc.) .
R33 was admitted to the facility on [DATE] with diagnoses that include need for assistance with personal cares, transient ischemic deafness, unspecified abnormalities of gait and mobility, generalized muscle weakness, repeated falls, rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints causing inflammation, pain, stiffness, and damage to the joints), bilateral primary osteoarthritis of the knee (a common type of joint disease that causes pain, stiffness, and swelling in the joints that occurs when the cartilage that cushions the ends of bones in the joints wears down over time), primary generalized osteoarthritis, and ankylosing spondylitis of the spine (a chronic inflammatory disease that primarily affects the spine. It causes inflammation of the joints between the vertebrae, leading to pain, stiffness, and fusion of the spine over time).
R33's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/16/25 documented that R33 had a Brief Interview for Mental Status (BIMS) score of 14, indicating R33 is cognitively intact.
Section J: Health Conditions indicates that R33 is on a pain medication regimen and received non-pharmacological interventions for pain.
Section J0300 indicates pain is present.
Section J0410 indicates pain is rarely or not at all present.
Section J0600 indicates mild pain, with a numeric rating of 3.
R33's Care Plan, initiated on 7/7/22, includes, in part:
525508
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525508 B.
Wing 01/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.