Inspection Reports for
Badger Prairie Health Care Center

WI, 53593

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 3 deficiencies/year

Deficiencies are regulatory findings recorded during state inspections.

35% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/year

Deficiencies per year

8 6 4 2 0
2023
2024
2025

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
NameTitleContext
Nurse Manager ENurse ManagerReported and investigated the allegation, visited resident R27, and coordinated follow-up actions.
CNA DCertified Nursing AssistantAccused by resident R27 of hitting her; removed from the floor and placed on paid administrative leave pending investigation.
DON BDirector of NursingNotified of allegations and confirmed failure to notify local law enforcement.
Social Worker FSocial WorkerFollowed 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
NameTitleContext
RN CRegistered NurseInterviewed regarding phone and visitor policies and R4's phone plan.
RN DRegistered NurseInterviewed regarding phone and visitor policies and R4's care plan.
CNA FCertified Nursing AssistantInterviewed about phone policy for R4 and visitor procedures.
Scheduler GInterviewed about visitor check-in and screening process.
SW ESocial WorkerInterviewed about visitor and phone call screening policies.
Receptionist HInterviewed about visitor and incoming call procedures.
DON BDirector of NursingInterviewed about visitor process, phone call screening, and abuse investigations.
CNA LCertified Nursing AssistantInterviewed about incidents involving R1 and other residents and interventions.
CNA MCertified Nursing AssistantInterviewed about interventions for R1.
SN ISupervisory NurseInterviewed about facility process for resident-to-resident altercations and reporting.
RN JRegistered NurseInterviewed about resident-to-resident altercation involving R1.
SN KSupervisory NurseReported awareness of resident-to-resident altercation and follow-up.

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
NameTitleContext
RN JRegistered NurseInterviewed regarding code status documentation and procedures
RN IP KInfection PreventionistInterviewed regarding code status documentation and procedures
RN NM LNurse ManagerInterviewed regarding code status documentation and procedures
SSD MSocial Service DirectorInterviewed regarding code status documentation and procedures
DON BDirector of NursingInterviewed regarding code status, hand hygiene, and immunization policies
FS CFood ServiceObserved not using soap when washing hands
CNA DCertified Nursing AssistantInterviewed and observed regarding food safety and hand hygiene
FSS OFood Services SupervisorInterviewed regarding food service cleanliness and cleaning policies
FSM NFood Service ManagerInterviewed regarding food service cleaning policies
RN QRegistered NurseObserved and interviewed regarding wound care and hand hygiene
RN Sup RRegistered Nurse SupervisorInterviewed regarding wound care and hand hygiene
Hospice RN FRegistered NurseObserved during wound care with multiple hand hygiene lapses
CNA ECertified Nursing AssistantObserved handwashing practices

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