Deficiencies (last 2 years)
Deficiencies (over 2 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
39 residents
Based on a July 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Jul 15, 2024
Visit Reason
Surveyor conducted 2 complaints and a verification visit at Lakeshore Manor, a CBRF located in Oshkosh, WI.
Complaint Details
Two complaints were investigated and both were unsubstantiated.
Findings
No violations of Chapter DHS 83 were issued. Both complaints were unsubstantiated. Five violations from a previous Statement of Deficiency dated 01/29/2024 were corrected.
Report Facts
Revisit fee: 200
Previous violations corrected: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
Surveyor conducted a desk review survey to investigate one self-reported incident.
Complaint Details
Investigation of one self-reported incident; no deficiencies found.
Findings
No deficiencies were identified during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 29, 2024
Visit Reason
A Verification Visit, Self-Report Review, and Complaint Investigation were conducted to determine if Lakeshore Manor was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related and included a complaint investigation. The substantiation status is not explicitly stated.
Findings
The Department issued a Statement of Deficiency (SOD) # EXJH13 for violations related to medication administration and other regulatory requirements. Enforcement actions including a forfeiture totaling $10,650 were imposed, and special orders were issued requiring corrective measures and staff training.
Deficiencies (1)
Medication administration deficiency identified in Statement of Deficiency EXJH13
Report Facts
Forfeiture amount: 10650
Reduced forfeiture amount: 6922.5
Forfeiture by tag: 1000
Forfeiture by tag: 200
Forfeiture by tag: 7350
Forfeiture by tag: 2100
Inspection fee: 200
Compliance timeframe: 45
Appeal timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 5
Date: Jan 17, 2024
Visit Reason
The surveyor conducted unannounced onsite visits to investigate 5 complaints, 2 self-reports, and to conduct a verification visit. Two of the complaints were substantiated.
Complaint Details
The investigation was complaint-driven, triggered by concerns about notification failures, medication administration, discharge procedures, and fall prevention. Two of five complaints were substantiated.
Findings
Five deficiencies were identified including 2 repeat deficiencies. Deficiencies included failure to notify legal representatives and physicians of incidents, inadequate continuing education for staff, improper involuntary discharge procedures, failure to ensure residents received all prescribed medications, and inadequate assessments and interventions following resident falls.
Deficiencies (5)
Failure to immediately notify resident's legal representative and physician of incidents or injuries, specifically related to Resident 1's multiple falls and injuries.
Failure to ensure 3 employees received at least 15 hours of continuing education including required topics during 2023.
Involuntary discharge of Resident 4 without assisting in locating or ensuring a suitable living arrangement, resulting in a 15-day hospital stay.
Failure to ensure Resident 1 and Resident 2 received all prescribed medications, with multiple missed doses due to medication unavailability and refill issues.
Failure to conduct adequate post-fall assessments and implement effective interventions for Residents 1 and 3 after frequent falls, including lack of supervision, failure to use assistive devices, and lack of injury prevention measures.
Report Facts
Complaints investigated: 5
Complaints substantiated: 2
Deficiencies identified: 5
Repeat deficiencies: 2
Resident 1 falls: 5
Resident 3 falls: 23
Resident 3 unwitnessed falls: 19
Resident 3 recent falls: 7
Resident 2 missed sertraline doses: 16
Resident 2 missed potassium doses: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Wellness A | Regional Director of Wellness | Interviewed regarding Resident 1's falls and medication issues; provided investigation documentation. |
| Director of Wellness C | Director of Wellness | Negligent in follow-up of Resident 1 after falls and injuries. |
| Regional Director of Operations E | Regional Director of Operations | Interviewed about plan of correction and tracking system for falls. |
| Caregiver F | Caregiver | Interviewed about medication issues and Resident 3's condition. |
| Caregiver L | Caregiver | Interviewed about continuing education and Resident 3's falls. |
| Caregiver N | Caregiver | Did not complete required continuing education. |
| Manager B | Manager | Provided documentation and interviews regarding medication issues and continuing education. |
| Nurse Practitioner P | Nurse Practitioner | Provided medical opinions regarding Resident 4's care and discharge. |
| MCO Coordinator Q | Managed Care Organization Coordinator | Expressed concerns about Resident 4's discharge and placement. |
| Caregiver K | Caregiver | Interviewed about Resident 3's fall risk. |
| Caregiver J | Caregiver | Interviewed about Resident 3's footwear and fall prevention. |
| DOO F | Regional Director of Operations | Interviewed about fall prevention plan of correction and staff changes. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
A Verification Visit and Complaint Investigation were conducted on April 11, 2023, at Lakeshore Manor to determine if the facility was in substantial compliance with Wisconsin statutes and administrative codes governing community-based residential facilities.
Complaint Details
The visit was complaint-related, conducted to verify compliance with applicable statutes and administrative codes. Specific substantiation status is not stated.
Findings
The Department issued a Statement of Deficiency (SOD # EXJH12) for violations of Wis. Stat. ch. 50 and Wis. Admin. Code ch. DHS 83, resulting in a total forfeiture of $2,675.00 imposed on the licensee. An inspection fee of $200 is also being assessed for a revisit to verify correction of prior violations.
Report Facts
Forfeiture amount: 2675
Forfeiture amount: 200
Forfeiture amount: 2475
Reduced forfeiture amount: 1738.75
Inspection fee: 200
Days to achieve compliance: 45
Days to request extension: 10
Days to pay forfeiture: 10
Days to request hearing: 10
Days to pay revisit fee: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kenneth Brotheridge | Assisted Living Director | Signed the Notice and Order letter |
| Vicky Wittman | Assisted Living Regional Director | Contact person for questions about the letter |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Apr 11, 2023
Visit Reason
Surveyor conducted a standard survey, verification visit, and a complaint investigation at Lakeshore Manor in Oshkosh due to a complaint which was substantiated.
Complaint Details
The complaint was substantiated. The investigation found that Resident 1 did not receive prescribed Eliquis medication due to pharmacy issues related to high copay and lack of approval from the responsible party, and the facility did not document notifying the physician about the medication not being administered.
Findings
Two new deficiencies were identified: one related to staff not completing required continuing education hours including training in standard precautions and medications, and another related to a resident not receiving prescribed medication (Eliquis) as ordered, resulting in hospitalization and discovery of bilateral deep vein thrombosis.
Deficiencies (2)
Staff did not receive at least 15 hours per calendar year of continuing education including required training in standard precautions and medications for 1 of 1 employee file reviewed.
Resident 1 did not receive prescribed Eliquis medication as ordered, leading to hospitalization and diagnosis of bilateral deep vein thrombosis.
Report Facts
Census: 37
Continuing education hours completed: 12.75
Revisit fee: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident Program Assistant A | Resident Program Assistant | Named in continuing education deficiency for incomplete required training |
| Human Resource Director B | Human Resource Director | Interviewed regarding Resident Program Assistant A's continuing education |
| Regional Director of Wellness E | Regional Director of Wellness | Interviewed regarding Resident 1's Eliquis medication |
| Assistant Wellness Director F | Assistant Wellness Director | Verified responsible party visits and communicated with surveyor about medication documentation |
| Pharmacist G | Pharmacist | Interviewed regarding Eliquis medication order and pharmacy communication |
| Nurse I | Nurse | Interviewed regarding facility notification to physician about medication not administered |
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