Inspection Reports for
Brown Deer Place

The program was cited for multiple regulatory insufficiencies including incomplete incident report policies lacking witness statement requirements, failure to document occurrences differing from tenants' normal status, incomplete background checks and evaluations for staff, failure to complete tenant evaluations with significant changes, failure to document nurse's notes by exception, and failure to update service plans reflecting tenants' current needs and behaviors.

The investigation was related to complaints #124468-C and #127787-C and incident #125841-I. There were no regulatory insufficiencies identified related to complaint #125118-C.

The program failed to have complete policies and procedures for incident reporting, medication administration, service plans, documentation, and food safety. Multiple incidents lacked proper documentation, medication administration was not consistently recorded, and food safety protocols were not fully followed. Staff training and service plan updates were also deficient.

The complaint investigation was triggered by allegations that Staff A administered higher doses of Risperidone than prescribed to Tenant #1 and failed to report the medication errors and suspected abuse in a timely manner. The investigation substantiated these concerns, leading to Staff A's termination and re-education of all staff.

The investigation found that staff failed to follow medication administration policies, including giving a tenant (Tenant #1) more Risperidone medication than prescribed and storing medications in unlocked areas accessible to tenants. Staff also failed to report suspected abuse promptly. Tenant #1 was subjected to chemical restraints without proper safeguards, and staff behavior toward the tenant was inappropriate.

Investigation of Complaint #123059-C found failure to ensure signed and dated service plans for Tenant 2.

The program failed to ensure that the service plan was signed and dated for 1 of 4 tenants reviewed (Tenant 2). The service plan for Tenant 2 was unsigned and undated since admission.

The program failed to protect Tenant #1 from being subjected to chemical restraints by administering higher doses of Risperidone than prescribed. Staff did not follow medication administration policies and failed to report suspected abuse or medication errors promptly.

No regulatory insufficiencies were cited during the investigation into Complaint #116587-C, Incident #117795-I, Complaint #117824-C, or Complaint #118690-C. Regulatory insufficiencies were cited during the investigation into Complaint #115147-C and Complaint #116487-C.

The investigation found that the program failed to produce detailed incident reports for 2 of 6 discharged tenants and failed to ensure service plans addressed the needs of current and discharged tenants. No regulatory insufficiencies were cited for other complaints investigated.

The inspection included investigation of complaints #112945-C and #114783-C. No regulatory insufficiencies were cited related to complaint #114420-C.

The Program failed to follow established policies related to incident report completion, medication administration by qualified staff, consistent medication administration as prescribed, timely nurse delegation training, proper service plan updates and signatures, dementia-specific training within 30 days of hire, dependent adult abuse training within six months, and ensuring drivers had appropriate licenses. No regulatory insufficiencies were found related to complaint #114420-C.

The visit was complaint-related due to an alleged theft incident involving Tenant C1. The complaint was substantiated by the finding that no incident report was completed as required.

The program failed to follow established policies and procedures regarding the completion of incident reports related to the alleged theft of checks from a discharged tenant. An incident report was not completed despite the incident being reported and investigated.

The inspection found multiple regulatory insufficiencies related to staff training and background checks, including failure to provide required dependent adult abuse training, incomplete criminal and abuse background checks prior to employment, failure to submit evaluations for staff with criminal histories, and deficiencies in dementia-specific education and hands-on training for staff.

The investigation was triggered by complaints #91579-C, #94972-C, and incident #95191-I. Complaint #92892-C was also investigated but no regulatory insufficiencies were found. The complaint investigation found failures in treatment adequacy, assessment completion, and service plan updates.

The program failed to adequately meet the treatment needs of one former tenant (Tenant C6) with significant wounds and ulcers, failed to complete an initial assessment for a recently admitted tenant (Tenant #2), and failed to update service plans for four tenants (C1, C6, #7, #9) as their needs changed. No regulatory insufficiencies were cited during the infection control survey or investigation of Complaint #92892-C.

The program failed to adequately meet the treatment needs of one former tenant (Tenant C6), resulting in severe pressure ulcers and inadequate wound care management. The facility did not implement appropriate treatment orders despite multiple reports and communications with the tenant's physician.