Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
May 14, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to notify a resident's Power of Attorney for Healthcare (POAHC) of changes in condition, failure to implement fall interventions for a resident with a history of falls, and failure to ensure accurate medication administration for a resident.
Findings
The facility failed to notify the POAHC of bruising from multiple falls for one resident, did not implement fall interventions or safety measures for a resident at high risk for falls, and missed a medication hold order related to a urinary stent removal appointment for another resident. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Complaint Details
The complaint investigation revealed that the facility failed to notify the POAHC of bruising injuries for resident R1, failed to implement fall interventions for R1 despite multiple falls, and missed a medication hold order for resident R7 related to a urinary stent removal appointment. POAHC-E expressed distress over lack of notification and concerns about fall prevention. Interviews with the Director of Nursing and Admissions Director confirmed these failures and process changes were made after the errors were identified.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility did not notify the Power of Attorney for Healthcare (POAHC) of a change in condition involving bruising from multiple falls for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not implement fall interventions or safety measures to prevent future falls or injury for one resident with a history of multiple falls. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure accurate administration of medication by missing an order to hold clopidogrel prior to a urinary stent removal appointment for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident falls: 7
Fall risk assessment score: 15
BIMS score: 0
BIMS score: 13
Medication dosage: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed regarding failure to notify POAHC-E of bruising and failure to implement fall interventions; confirmed lack of notification and fall interventions. |
| AD-D | Admissions Director | Interviewed regarding missed stent removal appointment and medication hold order for R7; confirmed process changes after error. |
Inspection Report
Routine
Deficiencies: 12
Jan 28, 2025
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide timely transfer and bed hold notices, inadequate pressure ulcer care, inappropriate catheter care, insufficient monitoring of weight loss, improper respiratory care, unsafe medication administration practices, food safety violations, incomplete medical records, inadequate infection prevention and control, inconsistent antibiotic stewardship, and failure to offer recommended pneumococcal vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to provide a written transfer notice to resident or representative before transfer or discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide bed hold notice in writing when resident leaves for therapeutic leave. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate pressure ulcer care including inaccurate wound assessments and failure to include pressure injury diagnosis on assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Inappropriate catheter care including flushing catheter without physician order and failure to document urine color. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor weight loss adequately and lack of current order for weight monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Inappropriate respiratory care with resident self-administering nebulizer treatment incorrectly. | Level of Harm - Minimal harm or potential for actual harm |
| Unsafe medication administration practices including medication left at bedside without self-administration assessment or physician order and signing out medications as administered when not given. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food safety including lack of monitoring food temperatures, improper sanitizing solution testing, expired food items, inadequate hand hygiene during meal service, and improper cold food holding temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Incomplete medical records with missing pre and post-dialysis communication forms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program including lack of enhanced barrier precautions for residents with wounds or devices, missed residents on infection control line list, and failure to perform hand hygiene between residents during medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an antibiotic stewardship program consistently, including lack of stop dates on antibiotic orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, including failure to offer PCV20 vaccine to eligible residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 24
Residents sampled: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 52
Residents affected: 1
Residents affected: 4
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-G | Licensed Practical Nurse | Signed out medication treatment but did not administer it to resident R15 |
| DON-B | Director of Nursing | Interviewed regarding multiple deficiencies including catheter care, wound care, medication administration, dialysis communication, antibiotic stewardship, and vaccination program |
| NHA-A | Nursing Home Administrator | Interviewed regarding transfer notices, medication administration, wound care, and vaccination program |
| IP-K | Infection Preventionist | Interviewed regarding infection control line list omissions and antibiotic stewardship |
| LPN-F | Licensed Practical Nurse | Interviewed regarding catheter flushing and nebulizer treatment |
| RNM-C | Registered Nurse Manager | Interviewed regarding wound care and pressure ulcer assessments |
| CNA-J | Certified Nursing Assistant | Reported catheter clots and flushing for resident R19 |
| DM-N | Dietary Manager | Interviewed regarding food safety and kitchen practices |
| CK-O | Cook | Observed during meal service with improper glove use and hand hygiene |
| DA-P | Dietary Aide | Observed during meal service with improper glove use and hand hygiene |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 25, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 28, 2022
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate treatment and care according to orders and professional standards, specifically related to a resident (R48) who experienced significant unmonitored weight loss.
Findings
The facility failed to weigh resident R48 per protocol and physician instructions, resulting in delayed awareness of significant weight loss by the Dietician. Nutritional interventions were insufficient, and monthly weights were not consistently obtained. The resident refused many meals, and family-provided food stopped after a few weeks. The Dietician did not intervene timely due to assumptions about diuretic-related weight fluctuations.
Complaint Details
The complaint investigation found that the facility did not ensure appropriate monitoring and intervention for resident R48's significant weight loss. The weight loss was substantiated as the Dietician confirmed a 6.59% weight loss over approximately six weeks. The facility failed to conduct monthly weights in July, and no documented resident refusal was found. Nutritional interventions were limited, and communication gaps existed between nursing and dietary staff.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to weigh resident R48 per facility protocol and physician instructions, leading to unmonitored significant weight loss. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss percentage: 6.59
Meals refused: 45
Meals eaten less than 25%: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietician-D | Corporate Dietician | Interviewed regarding weight loss and nutritional interventions for resident R48 |
| DON-B | Director of Nursing | Interviewed and confirmed missing monthly weight and lack of documented resident refusal for July weight |
| DM-C | Dietary Manager | Provided dietary progress notes and interviewed about nutritional interventions and family food provision |
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