Alden Meadow Park Hcc
ALDEN MEADOW PARK HCC in CLINTON, WI — inspection on January 30, 2025.
Found 2 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
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
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CLINTON, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ALDEN MEADOW PARK HCC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.