Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
226% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 30, 2025
Visit Reason
The inspection was conducted to investigate complaints related to medication administration, wound care, resident safety regarding smoking/vaping, and medication errors at Beloit Health and Rehabilitation Center.
Complaint Details
The complaint investigation focused on medication administration errors, wound care deficiencies, inadequate supervision related to smoking/vaping, and medication errors for resident R2 and wound care for resident R1. The investigation found substantiated deficiencies in all these areas.
Findings
The facility failed to promptly notify a physician when a resident (R2) missed antipsychotic medications for several days, did not complete wound care as ordered for residents (R1 and R2), failed to update care plans after a resident was observed vaping in the facility, and did not ensure residents were free from significant medication errors. Documentation of assessments, notifications, and treatments was frequently missing.
Deficiencies (5)
Facility did not promptly notify and consult with a physician when resident R2 missed antipsychotic medication for several days.
Facility did not ensure resident R1 received treatment and care according to orders and did not complete full wound assessment upon hospital return.
Facility did not ensure resident R2 received appropriate pressure ulcer care and wound treatments were frequently not documented as completed.
Facility failed to provide adequate supervision and update care plan for resident R2 after being observed vaping in the facility.
Facility did not ensure resident R2 was free from significant medication errors related to missed doses of Seroquel over several days.
Report Facts
Missed medication documentation: 10
Wound care missed treatments: 26
Wound care missed treatments: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding medication administration, wound care documentation, and vaping incidents; confirmed expectations for notification and documentation. |
| RN D | Registered Nurse | Interviewed regarding medication administration procedures and documentation requirements. |
| LPN E | Licensed Practical Nurse | Interviewed regarding medication administration procedures and notification protocols. |
| ADON/WN C | Assistant Director of Nursing/Wound Nurse | Interviewed regarding medication administration, wound care documentation, and vaping incidents. |
| LPN G | Licensed Practical Nurse | Showed surveyor the facility's contingency medication supply. |
| RN F | Registered Nurse | Interviewed regarding signing out treatments on the Treatment Administration Record. |
Inspection Report
Routine
Deficiencies: 17
Date: Sep 12, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, medication management, infection control, staffing, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; inadequate grievance documentation and resolution; incomplete baseline care plan review within 48 hours; incomplete person-centered care plans; failure to ensure resident participation in care planning; medication errors; insufficient nursing staff; improper medication storage and labeling; failure to prevent medication errors; inadequate infection prevention and control program; failure to ensure palatable food temperatures; delayed meal service; and failure to monitor antibiotic use appropriately.
Deficiencies (17)
Facility did not ensure a safe, clean, comfortable, and homelike environment for residents, including unclean floors, broken furniture, and disrepair in resident rooms.
Facility failed to ensure grievances were documented and thoroughly resolved for residents.
Facility did not ensure baseline care plan was reviewed with resident/representative and provided within 48 hours of admission.
Facility did not develop a comprehensive person-centered care plan reflecting resident's individualized preferences.
Facility did not ensure resident or representative participation in care planning process.
Facility failed to ensure timely transcription and administration of physician orders, resulting in delayed treatment.
Facility failed to provide necessary services to maintain good nutrition, grooming, personal and oral hygiene for residents unable to carry out ADLs.
Facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards to promote healing and prevent infection.
Facility did not ensure resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, including unsafe charging of electric wheelchairs and lack of smoking assessments.
Facility failed to provide enough nursing staff to meet resident needs and did not have a licensed nurse in charge on each shift, resulting in long call light wait times and unmet care needs.
Facility did not provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals to meet resident needs, including medication errors and improper medication administration.
Facility failed to ensure residents were free from significant medication errors, including missed insulin administration leading to hospitalization.
Facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards, including expired medications and undated opened medications.
Facility did not ensure all residents received food at a palatable temperature; residents reported cold food and test tray foods were served cold and unpalatable.
Facility did not ensure meals and snacks were served at times in accordance with resident needs, preferences, and requests; meals were often served late.
Facility failed to provide and implement an infection prevention and control program consistent with national standards, including breaches in infection control technique and incomplete contact tracing and testing during a COVID outbreak.
Facility did not implement a program that monitors antibiotic use and did not follow antibiotic stewardship protocols, resulting in inappropriate antibiotic use and antibiotic resistance.
Report Facts
Medication error rate: 10.71
Nurse Aide Hours per Resident Day: 1.686
Nurse Aide Case Mix Hours per Resident Day: 2.291
Nurse Aide Adjusted Hours per Resident Day: 1.656
Certified Nursing Assistant Hours per Resident Day: 1.6
Certified Nursing Assistant Hours per Resident Day: 1.53
Certified Nursing Assistant Hours per Resident Day: 1.55
Certified Nursing Assistant Hours per Resident Day: 1.46
Certified Nursing Assistant Hours per Resident Day: 1.39
Certified Nursing Assistant Hours per Resident Day: 1.64
Certified Nursing Assistant Hours per Resident Day: 1.39
Certified Nursing Assistant Hours per Resident Day: 1.46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding housekeeping and smoking policy |
| DON B | Director of Nursing | Interviewed regarding multiple findings including grievances, care planning, medication errors, staffing, infection control, and antibiotic stewardship |
| MDS M | Minimum Data Set Coordinator | Interviewed regarding care planning and staffing |
| SW D | Social Worker | Interviewed regarding grievances, care planning, smoking evaluation, and staffing |
| HSK J | Housekeeper | Interviewed regarding cleaning schedules and floor cleaning |
| HSK K | Housekeeper | Interviewed regarding cleaning duties and staffing |
| MD Q | Maintenance Director | Interviewed regarding maintenance concerns |
| CNA AA | Certified Nursing Assistant | Interviewed regarding resident transfers and grievances |
| CNA BB | Certified Nursing Assistant | Interviewed regarding resident transfers and grievances |
| LPN O | Licensed Practical Nurse | Interviewed regarding care planning, medication administration, and wound care |
| CNA CC | Certified Nursing Assistant | Interviewed regarding resident care and pain management |
| RN G | Registered Nurse | Interviewed regarding resident care and nail care |
| CNA F | Certified Nursing Assistant | Interviewed regarding resident care and staffing |
| CNA S | Certified Nursing Assistant | Interviewed regarding staffing concerns |
| Scheduler E | Scheduler | Interviewed regarding staffing and scheduling |
| RN H | Registered Nurse | Observed medication administration and interviewed regarding medication errors |
| LPN I | Licensed Practical Nurse | Observed medication administration and interviewed regarding medication errors |
| ADON/IP C | Assistant Director of Nursing/Infection Preventionist | Interviewed regarding infection control, medication errors, and staffing |
| NP N | Nurse Practitioner | Interviewed regarding medication administration and hospitalization |
| CNA P | Certified Nursing Assistant | Interviewed regarding electric wheelchair charging |
| CNA R | Certified Nursing Assistant | Interviewed regarding resident care and infection control |
| CNA DD | Certified Nursing Assistant | Observed providing care with infection control breaches |
| NSD W | Nutrition Services Director | Interviewed regarding food temperatures and meal service |
Inspection Report
Routine
Deficiencies: 11
Date: Sep 10, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, staffing, medication management, food service, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; inadequate grievance documentation and resolution; incomplete care planning participation; failure to meet professional standards in services including medication administration and wound care; insufficient nursing staff leading to delayed resident assistance; medication errors; improper medication storage and labeling; and failure to serve meals at appropriate temperatures and times.
Deficiencies (11)
Failure to ensure a safe, clean, comfortable, and homelike environment for residents, including unclean floors and needed repairs in resident rooms.
Failure to document and resolve grievances for residents, including issues with Hoyer lift transfers and staff interactions.
Failure to ensure resident or representative participation in care planning and failure to revise care plans to reflect changes such as code status.
Failure to ensure services meet professional standards of quality, including delayed transcription of physician orders.
Failure to provide necessary assistance with activities of daily living including oral hygiene, bathing, grooming, and nail care.
Failure to provide appropriate pressure ulcer care and prevent new ulcers, including missed wound treatments.
Failure to provide sufficient nursing staff to meet resident needs, resulting in long call light wait times and delayed assistance.
Failure to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administering of medications, including medication errors.
Failure to ensure drugs and biologicals are labeled and stored according to professional standards, including expired medications and unlabeled eye drops.
Failure to serve food and drink at palatable temperatures and appropriate times, with residents reporting cold food and observed late meal service.
Failure to accurately report mandatory staffing information to CMS, with multiple quarters triggering for excessively low weekend staffing.
Report Facts
Medication errors: 3
Missed wound treatments: 11
Missed wound treatments: 7
Missed wound treatments: 4
CNA hours per resident day: 1.39
CNA hours per resident day: 1.64
CNA hours per resident day: 1.53
CNA hours per resident day: 1.55
CNA hours per resident day: 1.46
CNA hours per resident day: 1.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding housekeeping and maintenance issues, medication storage, and staffing. |
| DON B | Director of Nursing | Interviewed regarding grievances, oral hygiene, medication errors, wound care, medication storage, staffing, and meal service. |
| HSK J | Housekeeper | Interviewed regarding cleaning schedules and unclean floors. |
| HSK K | Housekeeper | Interviewed regarding cleaning duties and staffing. |
| MD Q | Maintenance Director | Interviewed regarding maintenance concerns and repair prioritization. |
| SW D | Social Worker | Interviewed regarding grievance follow-up and care conferences. |
| CNA AA | Certified Nursing Assistant | Interviewed regarding resident transfers and pain complaints. |
| CNA BB | Certified Nursing Assistant | Interviewed regarding resident transfers and pain complaints. |
| LPN O | Licensed Practical Nurse | Interviewed regarding wound care and medication administration. |
| RN H | Registered Nurse | Observed medication administration and interviewed regarding medication errors. |
| CNA L | Certified Nursing Assistant | Interviewed regarding oral care and medication storage. |
| Scheduler E | Scheduler | Interviewed regarding staffing and scheduling. |
| MDS M | Minimum Data Set Coordinator | Interviewed regarding care plan updates and staffing. |
| CNA Y | Certified Nursing Assistant | Interviewed regarding staffing and call light response. |
| CNA Z | Certified Nursing Assistant | Interviewed regarding staffing and call light response. |
| CNA R | Certified Nursing Assistant | Interviewed regarding oral care and staffing. |
| CNA F | Certified Nursing Assistant | Interviewed regarding oral care, nail care, and staffing. |
| RN G | Registered Nurse | Interviewed regarding nail care. |
| NSD W | Nutrition Services Director | Interviewed regarding meal service and food temperatures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure medication administration according to professional standards, specifically related to insulin administration for one resident (R4).
Complaint Details
The complaint investigation found that the facility did not administer prescribed insulin doses to resident R4 from 1/11/24 to 1/15/24, failed to document reasons for withholding insulin, and had difficulty contacting the Nurse Practitioner and on-call physician for clarification. Resident R4 was transferred to the Emergency Department due to these issues.
Findings
The facility failed to follow physician insulin orders and document the rationale for not administering insulin to resident R4, resulting in missed insulin doses from 1/11/24 through 1/15/24. This failure potentially caused harm by not providing necessary diabetes treatment, leading to R4's transfer to the Emergency Department.
Deficiencies (1)
Failed to ensure medication administration was provided according to professional standards for one resident by not following physician insulin orders and not documenting rationale for withholding insulin.
Report Facts
Residents sampled: 9
Residents affected: 1
Blood sugar readings: 211
Blood sugar readings: 74
Blood sugar readings: 125
Blood sugar readings: 167
Blood sugar readings: 303
Blood sugar readings: 47
Blood sugar readings: 54
Blood sugar readings: 182
Blood sugar readings: 275
Blood sugar readings: 321
Blood sugar readings: 314
Blood sugar readings: 398
Blood sugar readings: 564
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 2 | Notified R4's physician regarding admission and approval of hospital discharge orders | |
| Registered Nurse (RN) 3 | Notified on-call physician regarding high insulin dose and later contacted Nurse Practitioner | |
| Licensed Practical Nurse (LPN) 1 | Notified Nurse Practitioner regarding insulin dose and made additional calls with no response | |
| Assistant Director of Nursing (ADON) | Stated nurses were uncomfortable administering large insulin dose and contacted NP with no return calls | |
| Physician for R4 | Approved admitting orders including insulin dose and was unaware why NP did not return calls | |
| Director of Nursing (DON) | Aware of difficulty contacting NP or on-call physician for R4 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure residents receive and consume foods in the appropriate therapeutic diet, specifically for one resident (R4) who did not receive a controlled carbohydrate diet as ordered by her physician.
Complaint Details
Complaint investigation found that resident R4 did not receive the ordered controlled carbohydrate diet. The dietary manager confirmed the resident did not receive the correct diet on the day of inspection and was unaware of how long this had been occurring.
Findings
The facility failed to provide resident R4 with the prescribed renal, controlled carbohydrate diet. Observations and interviews confirmed that R4 received a lunch meal inconsistent with the ordered diet, and the dietary manager acknowledged the error and was unaware of the duration of the incorrect diet provision.
Deficiencies (1)
Facility did not ensure residents receive and consume foods in the appropriate therapeutic diet for 1 (R4) of 3 residents sampled for altered special diets.
Inspection Report
Routine
Deficiencies: 11
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, physician notification of resident condition changes, abuse reporting, infection control, medication administration, food safety, antibiotic stewardship, and immunization practices.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication self-administration orders, failure to notify physicians timely of resident condition changes, incomplete abuse investigations and reporting, inadequate assistance with activities of daily living, missed dialysis due to transportation issues, medication errors, food safety violations, infection control lapses, antibiotic stewardship deficiencies, and failure to properly offer and document influenza immunizations.
Deficiencies (11)
Facility did not ensure residents were clinically appropriate to self-administer medications and lacked proper orders for bedside medications.
Facility failed to immediately notify physicians of resident condition changes resulting in actual harm and potential for minimal harm.
Facility did not complete background checks and reference checks for multiple employees as required by policy.
Facility failed to timely report an alleged verbal abuse incident to the State Survey Agency and did not conduct a thorough investigation.
Facility did not ensure residents unable to perform activities of daily living received necessary grooming assistance; resident observed with unshaved chin hairs.
Resident missed dialysis due to facility's failure to ensure transportation was available for scheduled appointment.
Medication error rate exceeded 5%, including late administration and administration without a complete physician order.
Food was not stored, prepared, distributed, and served in accordance with professional standards, including staff personal items in food prep areas, dirty floors, dirty hood vents, uncovered and undated foods, milk not kept on ice, and wet stacking of dishes.
Facility failed to establish and maintain an infection prevention and control program, evidenced by leaking ductwork dripping onto clean linens in laundry area.
Facility did not ensure an antibiotic stewardship program with protocols and monitoring was in place; residents were treated with antibiotics without appropriate sensitivity testing or documentation.
Facility failed to offer and properly document influenza immunizations for residents, resulting in actual harm for one resident who contracted influenza and required hospitalization.
Report Facts
Medication error rate: 6.67
Residents affected by deficiencies: 1
Residents affected by deficiencies: 52
Residents affected by deficiencies: 21
Residents affected by deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Named in medication self-administration and medication error findings |
| DON B | Director of Nursing | Named in findings related to physician notification, abuse reporting, medication errors, antibiotic stewardship, and immunizations |
| CNA L | Certified Nursing Assistant | Named in abuse allegation and investigation |
| LPN J | Licensed Practical Nurse | Named in abuse allegation and investigation |
| CNA K | Certified Nursing Assistant | Named in abuse allegation and investigation |
| Business Office Manager F | Business Office Manager / Acting Human Resources Manager | Named in background check and reference check deficiencies |
| Pharmacist I | Pharmacist | Named in medication error findings |
| Hospice RN M | Hospice Registered Nurse | Named in medication error findings |
| DM D | Dietary Manager | Named in food safety deficiencies |
| NHA A | Nursing Home Administrator | Named in infection control deficiency |
| LA N | Laundry Aide | Named in infection control deficiency |
| DON B | Director of Nursing | Named in antibiotic stewardship and immunization deficiencies |
| ADON Z | Assistant Director of Nursing | Named in immunization deficiency |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident care, infection control, medication administration, food safety, antibiotic stewardship, and immunization practices.
Findings
The facility was found deficient in multiple areas including improper medication self-administration procedures, failure to notify physicians of resident condition changes, inadequate investigation and reporting of abuse allegations, insufficient assistance with activities of daily living, missed dialysis appointments due to transportation issues, medication errors, unsafe food storage and handling, inadequate infection prevention and control, and failure to properly offer and document influenza vaccinations.
Deficiencies (10)
Facility did not ensure residents were clinically appropriate to self-administer medications; 2 of 2 residents observed had unauthorized medications at bedside without proper orders or assessments.
Facility failed to immediately consult with physicians when residents had changes in condition, resulting in actual harm for 1 resident hospitalized due to lack of timely consultation.
Facility failed to timely report and thoroughly investigate an alleged verbal abuse incident involving a resident and staff member.
Facility did not ensure residents unable to perform activities of daily living received necessary assistance, evidenced by a resident with unshaved chin hairs despite requesting shaving assistance.
Facility missed a resident's dialysis appointment due to failure to ensure transportation was available.
Medication error rate exceeded 5%, including late administration and administration without a complete physician order.
Food was not stored, prepared, distributed, and served in accordance with professional standards, including staff personal items in food prep areas, dirty floors and vents, uncovered and undated foods, milk not kept on ice, and wet stacking of dishes.
Facility failed to establish and maintain an infection prevention and control program, evidenced by leaking duct work dripping onto clean linens in laundry area.
Facility did not ensure an antibiotic stewardship program with protocols and monitoring was in place, resulting in residents being treated with antibiotics without appropriate sensitivity testing or documentation.
Facility failed to offer and document influenza immunizations properly, resulting in a resident not receiving the vaccine and subsequently contracting influenza A leading to hospitalization and cardiac arrest.
Report Facts
Medication error rate: 6.67
Residents affected by medication self-administration deficiency: 2
Residents affected by failure to consult physician: 2
Residents affected by abuse reporting deficiency: 1
Residents affected by ADL assistance deficiency: 1
Residents affected by missed dialysis: 1
Residents affected by antibiotic stewardship deficiency: 5
Residents affected by influenza immunization deficiency: 3
Residents census: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Interviewed regarding medication self-administration and medication administration timing |
| DON B | Director of Nursing | Interviewed regarding medication self-administration, physician notification, abuse reporting, ADL assistance, medication errors, antibiotic stewardship, and influenza immunization |
| LPN H | Licensed Practical Nurse | Interviewed regarding medication self-administration |
| CNA L | Certified Nursing Assistant | Involved in abuse allegation incident |
| LPN J | Licensed Practical Nurse | Involved in abuse allegation incident and medication administration |
| CNA K | Certified Nursing Assistant | Involved in abuse allegation incident |
| ADON C | Assistant Director of Nursing | Interviewed regarding abuse allegation and influenza vaccination documentation |
| NHA A | Nursing Home Administrator | Interviewed regarding laundry room duct leak |
| LA N | Laundry Aide | Observed folding linens under leaking duct work |
| Pharmacist I | Pharmacist | Interviewed regarding medication orders and patches |
| Hospice RN M | Hospice Registered Nurse | Interviewed regarding medication patch orders |
| Former ADON Z | Former Assistant Director of Nursing | Interviewed regarding influenza vaccination administration |
| DS V | Dietary Staff | Interviewed regarding food safety observations |
| DM D | Dietary Manager | Interviewed regarding food safety observations |
| DS GG | Dietary Staff | Interviewed regarding food safety observations |
| DS FF | Dietary Staff | Interviewed regarding food safety observations |
| DS EE | Dietary Staff | Interviewed regarding food safety observations |
| MT W | Maintenance | Interviewed regarding laundry room duct leak |
| PT AA | Pharmacy Technician | Interviewed regarding influenza vaccination documentation |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 12, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify the State Long Term Care Ombudsman of resident discharges and transfers, failure to provide written notice of bed-hold policies to residents or their representatives, untimely smoking assessments for residents who smoke, and unsafe food handling and sanitation practices in the facility.
Complaint Details
The visit was complaint-related due to allegations of failure to notify the Ombudsman of resident discharges and transfers, failure to provide bed-hold notices, untimely smoking assessments, and unsafe food handling practices. The deficiencies were substantiated as documented in the findings.
Findings
The facility failed to notify the Ombudsman of resident discharges and transfers for multiple residents, did not provide written bed-hold notices at discharge, did not complete timely smoking assessments for residents who smoke, and failed to maintain a safe and sanitary food preparation environment including unclean stove hood, ice machine, meat slicer, uncovered microwaved food, improperly thawed meat, and unlabeled opened food items.
Deficiencies (4)
Failure to notify the Office of the State Long Term Care Ombudsman of discharged residents for 1 of 18 sampled and 3 supplemental residents.
Failure to provide written notice of bed-hold policy duration and associated costs to residents or their representatives at discharge for 1 of 18 sampled and 3 supplemental residents.
Failure to ensure timely smoking assessments for residents who smoke for 1 of 2 sampled and 2 supplemental residents.
Failure to maintain a safe and sanitary environment in food preparation, storage, and distribution including dusty stove hood, dirty ice machine, unlabeled opened food items, dirty meat slicer, uncovered microwaved food, and improper thawing of meat.
Report Facts
Residents affected: 18
Supplemental residents affected: 3
Residents affected: 2
Supplemental residents affected: 2
Residents affected: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW C | Social Worker | Named in findings related to failure to notify Ombudsman and untimely smoking assessments |
| BOM D | Business Office Manager | Named in findings related to failure to provide bed-hold notices |
| DON B | Director of Nursing | Named in findings related to smoking assessments |
| DM E | Dietary Manager | Named in findings related to food safety and sanitation deficiencies |
| MM F | Maintenance Man | Named in findings related to cleaning of stove hood and ice machine |
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