Deficiencies (last 3 years)
Deficiencies (over 3 years)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
313% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Census: 41
Deficiencies: 4
Oct 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to ensure the residents' environment was clean, sanitary, and homelike, with issues including soiled bathrooms, loose toilet seats, and soiled privacy curtains. These deficiencies affected five residents and had the potential to cause infection spread, injury, and decline in residents' self-esteem.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Unlabeled urinal on the bathroom floor and soiled bathroom call light pull cord in residents R26 and R32's bathroom. | Level of Harm - Minimal harm or potential for actual harm |
| Soiled incontinent brief with bowel movement on the bathroom floor in residents R26 and R32's bathroom. | Level of Harm - Minimal harm or potential for actual harm |
| Bathroom between R9 and R23's rooms had a strong smell of urine, visibly soiled and sticky floor, one-inch brown smear on the wall, and soiled call cord. | Level of Harm - Minimal harm or potential for actual harm |
| Loose toilet seat and soiled privacy curtain in R22's bathroom. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Total residents present: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aid 5 | Certified Nurse Aid | Stated R26 uses the bathroom independently and R32 needed assistance with toileting and incontinence care; also stated R9 and R23 are capable of using the bathroom independently. |
| Social Service Director | Social Service Director | Verified observations of soiled urinal, call cords, soiled brief, bathroom conditions, and soiled curtain and loose toilet seat. |
| Maintenance Director | Maintenance Director | Verified observations of soiled urinal and bathroom conditions. |
Inspection Report
Routine
Census: 41
Deficiencies: 9
Oct 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, medication management, staffing, food and nutrition services, and staff training.
Findings
The facility was found deficient in multiple areas including maintaining a clean and safe environment, accurate resident assessments, proper medication and catheter orders, controlled substance management, staffing for dietary services, dishwasher sanitizer levels, and staff training for chemotherapy pump care. These deficiencies posed potential risks for resident harm and infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure residents' environment was clean, sanitary, and homelike, including soiled bathrooms and loose toilet seats affecting five residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident had an accurate Minimum Data Set (MDS) assessment regarding feeding tube use. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with an indwelling urinary catheter had a physician's order for catheter use and care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident with a feeding tube had a physician's order for care and management of the feeding tube. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident was administered medication properly; medication was left in the resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure controlled substances were double locked and properly signed out by nurses, risking diversion. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to designate a person as Director of Food and Nutrition Services, risking improper food preparation and storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain required sanitizer levels in the low temperature dishwasher, risking foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide effective training for staff on care and safety related to a resident's chemotherapy infusion pump. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 41
Residents affected: 41
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in deficiency related to lack of knowledge about chemotherapy pump and controlled substance count discrepancies |
| RN2 | Registered Nurse | Named in medication administration observation and controlled substance count discrepancies |
| Cook1 | Dietary Staff / Interim Director of Dietary | Named in deficiency related to lack of designated Director of Food and Nutrition Services |
| Director of Nursing | Director of Nursing | Named in multiple interviews confirming deficiencies and lack of physician orders |
| Administrator | Facility Administrator | Named in interviews confirming deficiencies and policy expectations |
| Corporate Clinical Consultant | Corporate Clinical Consultant | Named in interviews confirming lack of staff education and facility assessment gaps |
| Social Service Director | Social Service Director | Verified environmental deficiencies during observations |
| Maintenance Director | Maintenance Director | Verified environmental deficiencies during observations |
| RN2 | Registered Nurse | Confirmed no physician order for feeding tube flushing |
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 29, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to honor residents' rights to formulate advance directives, failure to notify residents' representatives about new treatments, and inadequate emergency response systems including CPR and code event management.
Findings
The facility failed to ensure accurate documentation and communication of residents' code status, failed to notify representatives of new treatments for residents with scabies, and lacked an effective emergency response system including proper use of paging, crash carts, and AED equipment during a resident's code event.
Complaint Details
The complaint investigation revealed issues with honoring residents' rights to formulate advance directives, failure to notify representatives of new treatments, and inadequate emergency response during a resident's code event. The investigation included interviews with staff and review of medical records and policies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure resident R6's code status was accurately documented and communicated, with conflicting DNR and full code orders and no evidence of discussion with the resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify residents' representatives (R3 and R7) of new treatments involving scabies medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have a system in place for emergency response including CPR, lack of crash carts, ineffective communication during a code event, and failure to bring AED to the scene. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 23
Dates of scabies treatment: 2
BIMS score: 14
BIMS score: 3
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-E | Licensed Practical Nurse | Performed CPR on resident R3 during code event and called 911 on personal cell phone |
| CNA-F | Certified Nursing Assistant | Attempted to call 911 and nurse during R3's code event but was unable to get through |
| RN-D | Registered Nurse | Assisted with CPR during R3's code event and arrived after LPN-E |
| DON-B | Director of Nursing | Interviewed regarding policies, notification failures, and emergency response system |
| SS-G | Social Service | Involved in POLST form completion and code status discussions with resident R6 |
| NHA-A | Nursing Home Administrator | Informed of deficiencies and involved in follow-up discussions |
| LPN-I | Licensed Practical Nurse | Interviewed about emergency supplies and procedures |
Inspection Report
Complaint Investigation
Deficiencies: 9
Aug 28, 2023
Visit Reason
The inspection was conducted due to complaints and self-reports regarding allegations of abuse, neglect, misappropriation of resident property, inadequate discharge procedures, unsafe environment, medication issues, and infection control concerns.
Findings
The facility failed to timely report an allegation of misappropriation of resident property, did not thoroughly investigate abuse allegations, failed to provide proper discharge documentation and physician orders for transfers, allowed a resident to elope without staff knowledge, had unsafe hot water temperatures, did not provide ordered therapy services timely, had an ineffective infection control program including inadequate water management and surveillance, and had an elevator with malfunctioning doors causing safety hazards.
Complaint Details
The complaint investigation included allegations of delayed reporting of abuse and misappropriation, inadequate investigations of abuse, improper discharge procedures, unsafe environment including elopement and hot water temperature, medication issues, lack of therapy services, infection control deficiencies, and elevator safety hazards.
Deficiencies (9)
| Description |
|---|
| Failure to timely report an allegation of misappropriation of resident property to the State Agency within required 24 hours. |
| Failure to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment including not interviewing other residents to determine scope. |
| Failure to provide transfer summaries and physician orders for resident transfers and discharges. |
| Failure to develop and provide a discharge summary including recapitulation of resident's stay for discharged resident. |
| Failure to ensure resident elopement was prevented and staff were aware when resident left the facility unsupervised. |
| Hot water temperature in resident room exceeded safe temperature range, reaching up to 124°F, risking burns. |
| Failure to provide ordered physical and occupational therapy services timely upon admission due to insurance issues and lack of wheelchair. |
| Failure to implement an effective infection prevention and control program including lack of effective water management plan and inaccurate infection surveillance. |
| Failure to maintain elevator doors in safe operating condition causing abrupt closing and safety hazards to residents and visitors. |
Report Facts
Amount missing from resident wallet: 40
Hot water temperature: 124
Date of survey completion: Aug 28, 2023
Therapy frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Interviewed regarding delayed reporting, investigations, discharge procedures, therapy services, and elevator safety. |
| DON-B | Director of Nursing and Infection Preventionist | Interviewed regarding investigations, infection control, therapy services, and elevator safety. |
| AD-H | Activity Director | Reported missing money incident and assisted resident R43. |
| SSD-D | Social Services Director | Participated in abuse investigations and discharge discussions. |
| LPN-G | Licensed Practical Nurse | Documented elopement incident involving resident R15. |
| Maintenance-F | Maintenance Staff | Provided information on elevator repairs and water temperature monitoring. |
| Therapy Director-N | Therapy Director | Interviewed regarding therapy services for resident R48. |
| CNA-R | Certified Nursing Assistant | Reported elevator door safety concerns. |
Inspection Report
Routine
Deficiencies: 15
Aug 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, safety, care, discharge planning, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs (wheelchair provision), incomplete advance directive documentation, unsafe environment (wall damage, hot water temperature), delayed reporting of alleged abuse, inadequate investigation of allegations, improper discharge planning and documentation, failure to provide ordered therapy timely, unsafe elevator operation, food storage violations, ineffective infection control program, and inadequate antibiotic stewardship.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to provide an appropriate wheelchair to resident R48, resulting in inability to get out of bed and receive therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document and clearly indicate resident R48's advance directive and code status in the medical record. | Level of Harm - Minimal harm or potential for actual harm |
| Unsafe environment due to large hole in drywall behind resident R3's bed and lack of maintenance documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Delayed reporting of alleged misappropriation of resident property (missing money) for resident R43 to the State Agency beyond required 24 hours. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate investigation of abuse and misappropriation allegations for residents R6 and R43, including failure to interview other residents to determine scope. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide physician orders and transfer summaries for residents R50 and R51 upon hospital transfer and discharge to another facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and document a discharge plan involving resident R51, family, and interdisciplinary team, including lack of referral documentation and evaluation of discharge needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a discharge summary for resident R51 including recapitulation of stay, final status, and medication list. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R15 eloped from the facility without staff knowledge or supervision; facility staff unaware until police notified them. | Level of Harm - Minimal harm or potential for actual harm |
| Hot water temperature in resident R49's room exceeded safe temperature range, reaching up to 124°F, risking burns. | Level of Harm - Minimal harm or potential for actual harm |
| Food storage violations including expired taco meat, unlabeled and undated opened cereal containers, and frost buildup in unit refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R48 did not receive ordered physical and occupational therapy upon admission due to insurance issues, resulting in delayed therapy start by over a month. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not implement an effective infection prevention and control program, including lack of a comprehensive Water Management Plan to prevent Legionella and inadequate infection surveillance. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R32 received an antibiotic for a urinary tract infection without documentation supporting infection, and was not included in the facility's infection surveillance log. | Level of Harm - Minimal harm or potential for actual harm |
| Facility elevator doors closed abruptly and quickly, causing residents and visitors to stumble and lose balance; one elevator was out of service for months awaiting parts. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Water temperature: 124
Frost buildup thickness: 1
Therapy delay days: 34
Scabies outbreak residents: 8
Elevator service last documented: May 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Therapy Director-N | Therapy Director | Reported delay in therapy for resident R48 due to insurance and wheelchair issues |
| Nursing Home Administrator-A | Nursing Home Administrator | Involved in discussions regarding resident transfers, therapy delays, elevator safety, and abuse reporting |
| Director of Nursing-B | Director of Nursing | Involved in resident care issues, therapy delays, transfer documentation, elevator safety, and infection control |
| Certified Nursing Assistant-CNA-R | Certified Nursing Assistant | Reported elevator door closing quickly and causing staff injuries |
| Licensed Practical Nurse-G | Licensed Practical Nurse | Documented elopement of resident R15 and provided statements about resident behavior |
| Activity Director-H | Activity Director | Received report of missing money from resident R43 and assisted in investigation |
| Social Services Director-D | Social Services Director | Participated in abuse investigations and discharge planning |
| Maintenance-F | Maintenance Staff | Reported elevator and refrigerator maintenance issues |
Inspection Report
Complaint Investigation
Deficiencies: 17
May 2, 2022
Visit Reason
The inspection was conducted based on complaints and allegations regarding medication self-administration, mail delivery, resident safety, abuse investigations, discharge planning, nutrition and hydration, pressure injury care, dialysis care, medication administration, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to assess residents for medication self-administration, inadequate mail delivery process, failure to protect residents during abuse investigations, lack of notification to Ombudsman for hospitalizations, incomplete care plans, inadequate pressure injury prevention and care, failure to monitor nutrition and hydration leading to immediate jeopardy, improper dialysis care, medication errors, unsafe food storage and preparation, and infection control deficiencies including improper PPE use and inaccurate infection surveillance reporting.
Complaint Details
The complaint investigation included allegations related to medication self-administration, mail delivery, resident safety, abuse, discharge planning, nutrition and hydration, pressure injury care, dialysis care, medication administration, infection control, and food safety. Immediate jeopardy was identified related to failure to ensure adequate hydration and nutrition for residents R36 and R33, both hospitalized with severe dehydration.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Level of Harm - Potential for minimal harm: 1
Level of Harm - Actual harm: 3
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to ensure residents were assessed for medication self-administration and medication was left unattended without proper assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide reasonable access to residents' mail on Saturdays and lack of mail delivery policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents during abuse investigations by allowing alleged perpetrators to continue working with residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify Ombudsman of resident hospitalizations for 3 residents. | Level of Harm - Potential for minimal harm |
| Failure to provide residents and representatives with written bed hold policy upon hospital transfer for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive care plans for residents' insomnia, transfer bar use, and fluid needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement an effective discharge plan for a resident desiring discharge to the community. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure basic life support including CPR was available 24 hours a day with current CPR certified staff scheduled on each shift. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide food stored, prepared, and served under sanitary conditions including expired food, inadequate temperature monitoring, and unsanitary kitchenettes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program with accurate infection surveillance and proper PPE use. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate dialysis care including monitoring of access site and blood pressure arm avoidance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide enough food and fluids to maintain residents' health, resulting in immediate jeopardy due to severe dehydration hospitalizations. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to try different approaches before using bed rails, assess risk of entrapment, review risks and benefits, obtain informed consent, and maintain bed rails properly. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing including timely assessment, treatment, and care plan revisions. | Level of Harm - Actual harm |
| Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents including unsafe smoking, maintenance hazards, and improper bed positioning. | Level of Harm - Actual harm |
| Failure to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medications and lack of psychiatric assessment and monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 28.57% due to improper administration of medications via gastrostomy tube and incorrect timing of medication administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication errors: 8
Pressure injury size: 2
Pressure injury size: 1
Pressure injury size: 0.1
Weight: 190
Weight: 202
Weight: 230
Weight: 233
Weight: 199
Weight: 199
Medication expiration: 4
Medication error rate: 28.57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-D | Registered Nurse | Observed improperly wearing PPE and improper medication administration. |
| LPN-J | Licensed Practical Nurse | Observed preparing medication for R142 and administering Benadryl early. |
| CNA-C | Certified Nursing Assistant | Alleged mistreatment of resident R2 and was allowed to work during investigation. |
| MS-E | Maintenance Supervisor | Alleged verbal abuse and intimidation of resident R4 and was not removed during investigation. |
| SW-F | Social Worker | Responsible for Medicare Part A notifications and PASARR completion. |
| DON-B | Director of Nursing | Involved in multiple findings including infection control, CPR certification, and care plan deficiencies. |
| NHA-A | Nursing Home Administrator | Involved in abuse investigation and food safety findings. |
| DM-K | Dietary Manager | Interviewed regarding food storage and preparation. |
| RD-Q | Registered Dietitian | Interviewed regarding nutritional assessments and hydration monitoring. |
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