Inspection Reports for Ascension Living Alexian Village – Milwaukee
WI, 53223
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 4, 2025
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to promptly resolve resident grievances, incomplete PASARR screenings, inadequate fall investigations, and failure to maintain residents' nutritional status.
Findings
The facility failed to ensure prompt resolution of resident grievances, did not complete timely PASARR screenings for mental disorders, inadequately investigated resident falls, and did not properly monitor or address significant weight loss in a resident. Deficiencies were noted in grievance handling, mental health screening, fall prevention and investigation, and nutritional care.
Complaint Details
The complaint investigation was triggered by concerns that the facility did not promptly resolve a resident's grievance about incontinence care, failed to complete required PASARR screenings after a 30-day exemption expired, inadequately investigated multiple falls of a high-risk resident, and did not address significant weight loss in a resident with no physician or dietician notification.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure prompt resolution of grievances filed by residents, including investigation steps and written decisions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents are accurately screened for mental disorders prior to expiration of 30-day PASARR exemption. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and investigation of falls for a resident at high risk for falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough food/fluids to maintain a resident's health, evidenced by significant unaddressed weight loss. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident weight loss: 10.1
Resident weight loss percentage: 6.61
Number of falls: 3
Fall risk score: 15
Fall risk score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator and Grievance Official | Named in grievance investigation and PASARR screening discussion |
| Director of Social Services (DSS)-E | Director of Social Services | Interviewed regarding resident grievance and PASARR screening |
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding fall investigations and grievance concerns |
| Director of Operations-C | Director of Operations | Interviewed regarding resident weight loss and nutritional concerns |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 28, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse involving inappropriate touching between residents and failure to provide necessary behavioral health care and services.
Findings
The facility failed to report an allegation of abuse in a timely manner, with a delay of at least twelve hours in notifying the Nursing Home Administrator. Additionally, the facility did not ensure that a resident exhibiting inappropriate behaviors received necessary psychiatric care or that the resident's Power of Attorney was contacted for consent. Both deficiencies were found to have minimal harm or potential for actual harm affecting a few residents.
Complaint Details
The complaint involved a resident (R2) reporting inappropriate touching by another resident (R1). The facility delayed reporting the incident to the Nursing Home Administrator by at least twelve hours. Interviews revealed staff confusion about reporting procedures. Additionally, the facility failed to notify the psychiatric provider or the resident's Power of Attorney about R1's behaviors and did not provide medically related social services after the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse involving inappropriate touching between residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents received necessary behavioral health care and services, including lack of psychiatric follow-up and failure to contact Power of Attorney for consent. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Delay in reporting: 12
Dates of incident and reporting: Incident occurred on 2025-06-02; Nursing Home Administrator notified on 2025-06-03
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Named in relation to delayed reporting and interview regarding abuse incident |
| Physical Therapist D | Physical Therapist | Reported abuse allegation and completed Stop and Watch form |
| RN C | Registered Nurse | Received Stop and Watch form but did not report abuse immediately |
| Director of Clinical Services B | Director of Clinical Services | Interviewed regarding abuse incident and behavioral health care |
| Nurse Practitioner E | Nurse Practitioner | Responsible for psychiatric care of resident R2; not updated on behaviors |
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 20, 2025
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to notify resident representatives of incidents, verbal and potential sexual abuse, misappropriation of resident property, drug diversion, and failure to timely report and investigate abuse and neglect incidents.
Findings
The facility was found to have multiple deficiencies including failure to notify resident representatives of falls, failure to protect residents from verbal and potential sexual abuse, misappropriation of resident property and narcotic drug diversion by staff, failure to timely report suspected abuse and neglect to the State Survey Agency, and incomplete investigations of abuse allegations.
Complaint Details
The complaint investigation involved multiple residents (R2, R3, R5, R7, R9, R10, R11, R12, R13, R16, R17) and staff members including CNA1 and RN1. Substantiated findings included verbal abuse by CNA1 and drug diversion by RN1. The facility failed to notify representatives, protect residents from abuse, prevent property misappropriation, and timely report and investigate incidents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to notify the resident representative of a fall for one of three residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect residents from verbal and potential sexual abuse by staff and other residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent misappropriation of resident property and narcotic drug diversion by a staff member. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report allegations of injury of unknown origin, verbal abuse, neglect, and drug diversion to the State Survey Agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct thorough investigations and timely submit reports of abuse allegations to the State Agency. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 17
Residents reviewed for abuse/neglect: 4
Residents affected by property misappropriation: 5
Cash missing: 352
Cash missing: 90
Cash missing: 1
Cash missing: 15
Dates of incidents: Falls, abuse, neglect, and drug diversion incidents occurred between 10/20/24 and 12/26/24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA1 | Certified Nursing Assistant | Named in verbal abuse finding involving resident R3 |
| RN1 | Registered Nurse | Named in narcotic drug diversion and property misappropriation findings |
| Administrator | Provided interviews and statements regarding expectations and findings | |
| Director of Nursing | Director of Nursing (DON) | Reviewed video footage and involved in drug diversion incident response |
| Staffing Coordinator | Interviewed regarding background check for RN1 | |
| Director of Nursing Prime Med | Interviewed regarding background checks and license status of RN1 | |
| Regional Clinical Nurse | Provided guidance on drug diversion incident response |
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report a suspected misappropriation of a resident's property and to thoroughly investigate a resident's fall incident.
Findings
The facility failed to report a resident's missing gold necklace to the Nursing Home Administrator within 24 hours and delayed the investigation. Additionally, the facility did not thoroughly investigate a resident's fall, focusing primarily on whether a dresser fell on the resident rather than the root cause of the fall or ensuring all dressers were safely secured.
Complaint Details
The complaint investigation focused on the facility's failure to report a resident's missing necklace within 24 hours and the inadequate investigation of a resident's fall where the resident was found under a fallen dresser. The investigation revealed delays in reporting and incomplete fall investigation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities regarding a resident's missing gold necklace. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, specifically inadequate investigation and root cause analysis of a resident's fall and failure to ensure dressers were safely secured. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 3
Residents currently residing: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator-A | Nursing Home Administrator | Named in the failure to be informed timely about missing necklace and fall investigation |
| Licensed Practical Nurse-E | Licensed Practical Nurse | Reported missing necklace to social worker and left voicemail for Nursing Home Administrator |
| Executive Director-B | Executive Director | Provided information on facility procedures for missing jewelry reporting and investigation |
| Certified Nursing Assistant-J | Certified Nursing Assistant | Documented observations related to resident fall incident |
| Licensed Practical Nurse-F | Licensed Practical Nurse | Documented observations and called EMS after resident fall |
| Certified Nursing Assistant-G | Certified Nursing Assistant | Documented observations related to resident fall incident |
| Acting Director of Nursing-C | Acting Director of Nursing | Documented observations and response to resident fall incident |
| Registered Nurse-H | Registered Nurse | Documented observations and assessment post resident fall |
| Scheduler-D | Scheduler | Provided explanation of staff scheduling related to resident care assignments |
| Plant Operations Director-I | Plant Operations Director | Provided information on dresser condition and fall investigation |
Inspection Report
Complaint Investigation
Deficiencies: 11
Oct 7, 2024
Visit Reason
The inspection was conducted due to multiple allegations of abuse, neglect, and failure to report incidents timely involving residents R5, R111, and R45, as well as concerns about care plan completeness, PASARR screening, pressure injury care, fall prevention, nutritional status, respiratory care, infection control, and food safety.
Findings
The facility failed to timely report abuse allegations, thoroughly investigate abuse and falls, provide comprehensive care plans for residents' needs including incontinence and pressure injuries, ensure PASARR screenings were completed accurately, maintain nutritional status monitoring, provide appropriate respiratory care, maintain infection control practices, and ensure food safety standards. Multiple residents were affected by these deficiencies.
Complaint Details
The complaint investigation involved allegations of abuse, neglect, failure to report abuse timely, inadequate investigation of abuse and falls, incomplete PASARR screening, inadequate care planning, failure to prevent pressure injuries, inadequate fall prevention, nutritional monitoring failures, respiratory care deficiencies, infection control lapses, and food safety violations affecting multiple residents including R5, R111, R45, R4, R52, R48, R55, R57, R38, R29, R43, R24, R44, and R60.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Level of Harm - Actual harm: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to timely report abuse allegations involving residents R5, R111, and R45. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate abuse allegations and falls, and failure to revise care plans accordingly. | Level of Harm - Minimal harm or potential for actual harm |
| Incomplete PASARR screening for residents R4 and R52. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive care plans for residents R48, R55, and R57 addressing oxygen needs, bowel monitoring, and incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and monitoring for resident R55's bowel regimen. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers for residents R5 and R48. | Level of Harm - Actual harm |
| Failure to ensure adequate supervision and fall prevention interventions for residents R38, R29, and R43. | Level of Harm - Actual harm |
| Failure to provide appropriate care and assessment for resident R57's urinary and bowel incontinence. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care for resident R48, including unlabeled oxygen tubing and humidification, incorrect oxygen flow rate, and lack of monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure, store, prepare, and serve food in accordance with professional standards, including food stored on the floor, expired milk, unclean dishwasher, and staff not wearing beard coverings. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement infection prevention and control program, including shared glucometer not cleaned between residents and catheter bag left on floor. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiencies cited: 12
Weight loss: 41.7
Weight loss: 32.8
Pressure injury size: 3
Pressure injury size: 2.5
Pressure injury size: 2.9
Pressure injury size: 1.5
Fall count: 7
Fall risk score: 23
Oxygen flow rate: 2
Oxygen flow rate: 3
Expired milk date: Sep 26, 2024
Ceiling opening size: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Previous NHA-D | Nursing Home Administrator | Named in relation to abuse allegation investigation and reporting delays |
| LPN-E | Licensed Practical Nurse | Reported concerns of possible retaliation and abuse involving resident R5 |
| CNA-F | Certified Nursing Assistant | Involved in abuse allegation and possible retaliation against resident R5 |
| RN-G | Registered Nurse | Provided statements regarding resident R5 and fall prevention |
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding care plans, oxygen orders, and fall prevention |
| Executive Director-C | Executive Director | Interviewed regarding multiple concerns including abuse investigations and kitchen observations |
| Assistant Director of Nursing (ADON)-M | Assistant Director of Nursing | Interviewed regarding care plan concerns and abuse investigations |
| Registered Dietician (RD)-T | Registered Dietician | Interviewed regarding weight loss monitoring and dialysis communication |
| Kitchen Manager (KM)-O | Kitchen Manager | Interviewed regarding kitchen conditions and food safety |
| LPN-P | Licensed Practical Nurse | Observed and interviewed regarding glucometer cleaning practices |
| LPN-Q | Licensed Practical Nurse | Observed and interviewed regarding glucometer cleaning practices |
| Wound Nurse-H | Wound Nurse | Provided wound care assessments and interventions for resident R5 |
| Admission Director-K | Admission Director | Interviewed regarding PASARR screening process |
| Admissions-L | Admissions Staff | Interviewed regarding PASARR screening completion |
| Certified Nursing Assistant (CNA)-N | Certified Nursing Assistant | Interviewed regarding incontinence care for resident R57 |
| MDS Coordinator-J | MDS Coordinator | Interviewed regarding care plan development and incontinence assessments |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 7, 2024
Visit Reason
The inspection was conducted due to allegations of abuse, neglect, and inadequate supervision related to multiple residents, including R45, R5, R111, R38, R29, and R43. The investigation focused on the facility's failure to timely report abuse allegations, thoroughly investigate incidents, and implement appropriate interventions to prevent accidents and falls.
Findings
The facility failed to timely report and thoroughly investigate multiple abuse allegations involving residents R45, R5, and R111. The investigation of abuse allegations was incomplete, with selective staff interviews and lack of evidence review. Additionally, the facility did not ensure adequate supervision and fall prevention interventions for residents R38, R29, and R43, resulting in multiple falls and injuries without proper root cause analysis or care plan updates.
Complaint Details
The complaint investigation revealed that the facility did not timely report abuse allegations involving residents R45, R5, and R111 to the State Survey Agency or law enforcement. The abuse investigations were incomplete, with limited staff interviews and no review of camera footage. Resident R45 reported being held down and changed against his will, resulting in shoulder pain and a suspected rotator cuff tear. The facility allowed a CNA accused of possible retaliation to continue working during the investigation. Falls involving residents R38, R29, and R43 were not thoroughly investigated, and fall prevention interventions were not consistently implemented or updated in care plans.
Deficiencies (2)
| Description |
|---|
| Failure to timely report suspected abuse and thoroughly investigate allegations involving residents R45, R5, and R111. |
| Inadequate supervision and failure to implement fall prevention interventions for residents R38, R29, and R43, resulting in multiple falls and injuries. |
Report Facts
Allegations not reported timely: 3
Number of falls: 7
Fall risk score: 23
BIMS score: 0
BIMS score: 8
BIMS score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Previous NHA-D | Nursing Home Administrator | Named in relation to delayed reporting and incomplete investigation of abuse allegations involving resident R45. |
| NHA-A | Nursing Home Administrator | Interviewed regarding concerns about abuse investigations and reporting. |
| CNA-F | Certified Nursing Assistant | Accused of possible retaliation against resident R5 and involved in abuse allegation with resident R45. |
| LPN-E | Licensed Practical Nurse | Reported concerns of possible retaliation by CNA-F against resident R5. |
| RN-G | Registered Nurse | Provided statements regarding resident R45 and fall prevention. |
| Dir Quality Mgmt/IP-I | Director of Quality Management/Infection Prevention | Reported initial knowledge of resident R45's abuse allegation. |
| Executive Director-C | Executive Director | Participated in interviews and exit meeting regarding abuse and fall concerns. |
| ADON-M | Assistant Director of Nursing | Participated in interviews and exit meeting regarding abuse and fall concerns. |
| DON-B | Director of Nursing | Interviewed regarding fall prevention and care plan adherence for resident R29. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Jul 1, 2024
Visit Reason
The inspection was conducted due to complaints regarding privacy breaches, delayed reporting of abuse allegations, inadequate investigations of abuse and neglect, and other concerns related to resident care and facility compliance.
Findings
The facility failed to ensure privacy and confidentiality of resident information, timely reporting and thorough investigation of abuse allegations, proper treatment and care according to professional standards, complete and accurate medical records, and adequate staff training in multiple required areas including infection control, resident rights, abuse prevention, communication, and compliance.
Complaint Details
The complaint investigation included allegations of privacy breaches, delayed reporting of abuse, inadequate investigations of abuse and neglect, failure to provide appropriate care, incomplete medical records, failure to offer COVID-19 immunizations, and lack of staff training.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility did not ensure privacy and confidentiality of personal health information for 9 residents as report sheets with personal information were left unattended in a common area. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not timely report an allegation of abuse involving a resident and failed to remove the alleged perpetrator from resident contact immediately. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not thoroughly investigate allegations of misappropriation, neglect, and mistreatment for 3 residents, including failure to interview witnesses and notify police when appropriate. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide appropriate treatment and care according to orders and resident preferences, including failure to monitor edema, obtain ordered labs timely, and schedule follow-up appointments, resulting in immediate jeopardy for one resident who later died. | Level of Harm - Immediate jeopardy to resident health or safety |
| Facility did not provide proper foot care for a resident with very long toenails and lacked documentation of podiatry visits. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure adequate supervision and accident hazard prevention for a resident who fell, with no fall investigation or staff statements documented. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not provide medically-related social services to help a resident achieve highest practicable well-being, including failure to monitor effectiveness of medication changes and develop person-centered approaches for anxiety. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not maintain complete and accurate medical records for 3 residents who expired in the facility, lacking documentation of death and related circumstances. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to offer COVID-19 immunization to 2 residents and did not properly document vaccination status. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not develop, implement, and maintain an effective training program for all staff, lacking documentation of required annual trainings including communication, resident rights, abuse prevention, infection control, compliance and ethics, QAPI, behavioral health, and educational hours for nurse aides. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected by privacy breach: 9
Residents affected by abuse reporting delay: 1
Residents affected by inadequate investigations: 3
Residents affected by incomplete medical records: 3
Residents affected by lack of COVID-19 immunization offer: 2
Certified Nursing Assistants without annual performance review: 5
Staff without required training: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Responsible for submitting abuse reports and acknowledged delay in reporting. |
| DON-B | Director of Nursing | Confirmed lack of staff training and incomplete fall investigation. |
| ADON-C | Assistant Director of Nursing | Involved in abuse investigation, fall response, and staff training discussions. |
| RN/Quality Management Director-E | RN/Quality Management Director | Completed abuse investigation for R5 and discussed COVID immunization issues. |
| RN-P | Registered Nurse | Provided statement regarding abuse allegation involving CNA-M. |
| CNA-M | Certified Nursing Assistant | Alleged perpetrator in abuse allegation and not immediately removed from resident contact. |
| SSD-D | Social Services Director | Responsible for interviewing residents during abuse investigations. |
| APNP-H | Advanced Practice Nurse Prescriber | Managed medication changes for resident R1 and discussed monitoring concerns. |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Apr 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to have a system in place to outline staff response for residents requiring cardiopulmonary resuscitation (CPR) and to maintain records documenting agency staff qualifications for CPR.
Findings
The facility lacked a system to ensure staff response during CPR events and did not maintain records verifying agency staff CPR qualifications. An incident involving resident R1 revealed that RN-D, an agency nurse, did not have current CPR certification at the time of the event, and staff were not properly coordinated during the emergency response.
Complaint Details
The complaint investigation focused on an incident where resident R1 fell and required CPR. RN-D, an agency nurse, left the resident to retrieve the AED despite the resident still having a pulse and respirations, and did not have an up-to-date CPR certification. Multiple staff interviews revealed lack of clear delegation and communication during the emergency. The facility did not have a formal written process for Code Blue events, and agency staff CPR certifications were not consistently verified.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide basic life support, including CPR, prior to arrival of emergency medical personnel, and failure to maintain records documenting agency staff CPR qualifications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 34
Current census: 78
Staff present at Mock Code Blue in-service: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-D | Registered Nurse (Agency Staff) | Named in deficiency for not having current CPR certification and leaving resident unattended during CPR event |
| ADON-H | Assistant Director of Nursing | Interviewed regarding incident response and staff education |
| DON-B | Director of Nursing | Interviewed about facility policies and staff CPR certification processes |
| Scheduler-C | Scheduler | Responsible for verifying staff certifications, including CPR |
| SS-E | Staffing Specialist (Agency) | Confirmed RN-D had expired CPR certification at time of incident |
Inspection Report
Complaint Investigation
Deficiencies: 6
Aug 9, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to notify providers of significant weight loss, lack of written transfer and bed hold notices for hospitalized residents, inadequate monitoring of antipsychotic medication adverse reactions, unlocked medication carts, and improper infection control practices.
Findings
The facility was found deficient in notifying providers of significant weight loss for one resident, providing written transfer and bed hold notices for three residents, monitoring adverse reactions to antipsychotic medication for one resident, securing medication carts properly, and implementing proper infection prevention and control practices during resident care.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to notify providers of significant weight loss, lack of written transfer and bed hold notices, inadequate monitoring of antipsychotic medication adverse reactions, unsecured medication carts, and improper infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to notify a provider of significant weight loss for one resident (R67). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written notification of transfer, including appeal rights and ombudsman contact, for three residents (R14, R21, R26). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide written bed hold notices for three residents (R14, R21, R26) transferred to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor one resident (R42) for adverse reactions to antipsychotic medication with a tardive dyskinesia screening assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Medication cart observed unlocked and unattended, allowing resident access to medications, affecting 14 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement proper infection prevention and control practices; staff did not remove gloves and cleanse hands appropriately during care for two residents (R6 and R21). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 14
Residents affected: 2
Weight loss percentage: 8.33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RD-E | Registered Dietitian | Interviewed regarding resident R67's significant weight loss and notification process |
| NP-F | Nurse Practitioner | Interviewed regarding notification of resident R67's weight loss |
| NHA-A | Nursing Home Administrator | Interviewed regarding transfer/discharge notification and medication cart security |
| SW-D | Social Worker | Interviewed regarding transfer/discharge and bed hold notification processes |
| DON-B | Director of Nursing | Interviewed regarding tardive dyskinesia screening and medication cart security |
| RN-C | Registered Nurse | Observed with unlocked medication cart and interviewed about medication cart security |
| LPN-G | Licensed Practical Nurse | Observed and interviewed regarding improper glove removal and hand hygiene during care |
| CNA-H | Certified Nursing Assistant | Observed and interviewed regarding improper glove removal and hand hygiene during care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 8, 2023
Visit Reason
The inspection was conducted due to concerns regarding the care and treatment of a resident (R1) with a stage 4 pressure injury, specifically related to the failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Findings
The facility failed to ensure that resident R1 received necessary treatment for a stage 4 pressure injury, resulting in a significant decline in the wound after the resident was moved to a new room without the ordered air mattress for approximately 8 days. Facility staff did not recognize the wound deterioration despite daily dressing changes, and documentation falsely indicated compliance with air mattress use.
Complaint Details
The investigation was complaint-related, focusing on the substantiated issue that the resident's air mattress was not moved with her to a new room for about 8 days, leading to a decline in her sacral pressure injury. Facility staff did not recognize the wound deterioration until identified by the Nurse Practitioner on 11/3/22.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for resident R1 with a stage 4 pressure injury. | Level of Harm - Actual harm |
Report Facts
Days without air mattress: 8
Wound measurements: 4.1
Wound measurements: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Reported the air mattress was not moved with the resident and was replaced after a couple of days. |
| Director of Nursing (DON)-B | Director of Nursing | Reported the Nurse Practitioner identified the missing air mattress and that rounds are conducted twice weekly to check air mattresses. |
| Social Service Director (SSD)-C | Social Service Director | Spoke with surveyor about the air mattress not moving with the resident. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 13, 2022
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's provision of dialysis care and infection prevention practices.
Findings
The facility failed to ensure that a resident's dialysis port was monitored and assessed for complications as required by professional standards, and the designated Infection Preventionist had not completed specialized infection control training, potentially affecting all residents.
Complaint Details
The complaint investigation found that the facility did not monitor or change the dressing of a resident's dialysis port as required, and the Infection Preventionist lacked required specialized training. The resident confirmed that dressing changes were only done at the dialysis clinic, not the facility.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide safe, appropriate dialysis care/services for a resident requiring such services; specifically, no evidence that the dialysis port was assessed for complications. | Level of Harm - Minimal harm or potential for actual harm |
| Designated Infection Preventionist did not complete specialized training in infection prevention and control. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Residents Affected: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Designated Infection Preventionist who had not completed specialized infection control training |
| RN-C | Registered Nurse | Interviewed regarding dialysis communication and monitoring of resident's dialysis port |
| NHA-A | Nursing Home Administrator | Informed of findings and communicated with DON regarding physician orders for dialysis port monitoring |
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