Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 10, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse involving a resident's allegation of physical abuse by a staff member.
Complaint Details
The complaint involved an allegation by resident R27 that a staff member hit her. The facility did not report this allegation to local law enforcement as required. The allegation was substantiated by interviews and record review. The staff member involved was removed pending investigation.
Findings
The facility failed to report an allegation of a staff member hitting a resident (R27) to local law enforcement as required by policy and state law. The investigation included interviews, record reviews, and assessments, confirming the allegation was not reported despite facility policies mandating immediate notification.
Deficiencies (1)
Failure to timely report suspected abuse involving misappropriation of resident funds/personal property and physical abuse to proper authorities.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager E | Nurse Manager | Reported and investigated the allegation, visited resident R27, and coordinated follow-up actions. |
| CNA D | Certified Nursing Assistant | Accused by resident R27 of hitting her; removed from the floor and placed on paid administrative leave pending investigation. |
| DON B | Director of Nursing | Notified of allegations and confirmed failure to notify local law enforcement. |
| Social Worker F | Social Worker | Followed up with resident R27 and conducted a climate survey of residents. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a facility survey completed on 08/29/2024 for Badger Prairie Hcc.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 8, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to ensure residents' rights to dignified existence, self-determination, communication, and protection from abuse, including concerns about phone and visitor screening policies and resident-to-resident physical abuse incidents.
Complaint Details
The complaint involved allegations that the facility did not ensure residents' rights to communication and visitation without interference, and failed to protect residents from physical abuse by another resident (R1). The complaint also included failure to timely report and properly investigate abuse incidents. The substantiation status is not explicitly stated in the report.
Findings
The facility failed to ensure residents could exercise their rights without interference, including improper screening of phone calls and visitors. Additionally, the facility failed to protect residents from physical abuse by another resident (R1), who was observed hitting multiple residents on several occasions. The facility also failed to timely report and thoroughly investigate abuse allegations as required.
Deficiencies (4)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, including screening of phone calls and visitors.
Failure to protect residents from physical abuse by another resident, including multiple incidents of hitting other residents with a pillow and shoe.
Failure to timely report suspected abuse to the appropriate authorities within required timeframes.
Failure to respond appropriately by thoroughly investigating allegations of abuse.
Report Facts
Number of shifts physically aggressive: 36
Number of shifts wandering into peers' rooms: 67
Number of times R1 hit R11 with a pillow: 4
Number of times R1 hit R2 with shoe insole: 3
Number of residents reviewed for abuse: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Interviewed regarding phone and visitor policies and R4's phone plan. |
| RN D | Registered Nurse | Interviewed regarding phone and visitor policies and R4's care plan. |
| CNA F | Certified Nursing Assistant | Interviewed about phone policy for R4 and visitor procedures. |
| Scheduler G | Interviewed about visitor check-in and screening process. | |
| SW E | Social Worker | Interviewed about visitor and phone call screening policies. |
| Receptionist H | Interviewed about visitor and incoming call procedures. | |
| DON B | Director of Nursing | Interviewed about visitor process, phone call screening, and abuse investigations. |
| CNA L | Certified Nursing Assistant | Interviewed about incidents involving R1 and other residents and interventions. |
| CNA M | Certified Nursing Assistant | Interviewed about interventions for R1. |
| SN I | Supervisory Nurse | Interviewed about facility process for resident-to-resident altercations and reporting. |
| RN J | Registered Nurse | Interviewed about resident-to-resident altercation involving R1. |
| SN K | Supervisory Nurse | Reported awareness of resident-to-resident altercation and follow-up. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 8, 2023
Visit Reason
The investigation was conducted due to complaints regarding resident rights violations related to phone and visitor screening, and allegations of resident-to-resident abuse incidents.
Complaint Details
The complaint investigation focused on allegations that the facility restricted a resident's phone use and screened visitors, violating resident rights, and that resident R1 physically abused other residents multiple times. The facility failed to report one abuse incident timely and did not conduct a thorough investigation.
Findings
The facility failed to ensure residents' rights to dignified existence, self-determination, and communication by screening phone calls and visitors, restricting a resident's phone use, and requiring visitor identification. Additionally, the facility failed to protect residents from physical abuse by another resident (R1), did not report abuse allegations timely to the State Agency, and did not thoroughly investigate abuse incidents.
Deficiencies (4)
Facility did not ensure residents' rights to make and receive phone calls without interference and screened visitors requiring identification, violating resident rights.
Resident R1 physically abused other residents (R2, R3, R11) on multiple occasions, including hitting with a pillow and shoe.
Facility failed to timely report alleged abuse involving R1 hitting another resident with a pillow to the State Agency.
Facility failed to thoroughly investigate the resident-to-resident abuse incident involving R1 hitting another resident with a pillow.
Report Facts
Number of shifts R1 was physically aggressive with staff in April 2023: 36
Number of shifts R1 wandered into peers' rooms in April 2023: 67
Number of times R1 hit R11 with a pillow: 4
Number of times R1 hit R2 in the face with shoe insole: 3
Number of times R1 hit R3 with shoe: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Interviewed about phone and visitor policies and R4's phone plan |
| RN D | Registered Nurse | Interviewed about phone and visitor policies and R4's care plan |
| CNA F | Certified Nursing Assistant | Interviewed about phone policy and visitor procedures, and R4's phone plan |
| Scheduler G | Scheduler | Interviewed about visitor check-in and screening procedures |
| SW E | Social Worker | Interviewed about visitor and phone call procedures and resident rights |
| Receptionist H | Receptionist | Interviewed about visitor and phone call procedures |
| DON B | Director of Nursing | Interviewed about visitor and phone call policies and abuse incident investigations |
| CNA L | Certified Nursing Assistant | Interviewed about resident-to-resident abuse incidents and interventions |
| CNA M | Certified Nursing Assistant | Interviewed about interventions for resident R1 |
| SN I | Supervisory Nurse | Interviewed about abuse incident reporting and investigation procedures |
| RN J | Registered Nurse | Interviewed about resident-to-resident altercation involving R1 |
Inspection Report
Routine
Census: 110
Deficiencies: 4
Date: May 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, food safety, infection prevention and control, and immunization policies at Badger Prairie Hcc.
Findings
The facility was found deficient in ensuring accurate and consistent documentation of residents' code status and advance directives, maintaining food service cleanliness and safety, implementing proper infection prevention and control practices including hand hygiene, and developing comprehensive policies for flu and pneumonia vaccinations.
Deficiencies (4)
Failed to ensure all residents were able to formulate an advance directive related to code status, with discrepancies found in documentation for multiple residents.
Food was not prepared in a clean and sanitary environment; dried food particles were found on mixers and pans were stacked wet after dishwashing.
Did not maintain an infection prevention and control program; staff failed to perform hand hygiene consistently during wound care and other care activities.
Facility lacked detailed policies and procedures for flu and pneumonia vaccinations including resident education and documentation requirements.
Report Facts
Residents affected: 3
Residents affected: 110
Residents affected: 4
Residents affected: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN J | Registered Nurse | Interviewed regarding code status documentation and procedures |
| RN IP K | Infection Preventionist | Interviewed regarding code status documentation and procedures |
| RN NM L | Nurse Manager | Interviewed regarding code status documentation and procedures |
| SSD M | Social Service Director | Interviewed regarding code status documentation and procedures |
| DON B | Director of Nursing | Interviewed regarding code status, hand hygiene, and immunization policies |
| FS C | Food Service | Observed not using soap when washing hands |
| CNA D | Certified Nursing Assistant | Interviewed and observed regarding food safety and hand hygiene |
| FSS O | Food Services Supervisor | Interviewed regarding food service cleanliness and cleaning policies |
| FSM N | Food Service Manager | Interviewed regarding food service cleaning policies |
| RN Q | Registered Nurse | Observed and interviewed regarding wound care and hand hygiene |
| RN Sup R | Registered Nurse Supervisor | Interviewed regarding wound care and hand hygiene |
| Hospice RN F | Registered Nurse | Observed during wound care with multiple hand hygiene lapses |
| CNA E | Certified Nursing Assistant | Observed handwashing practices |
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