Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Nov 11, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Lindengrove Menomonee Falls nursing home.
Findings
The facility was found deficient in multiple areas including failure to notify representatives of resident falls, failure to report allegations of neglect and abuse, inadequate investigation of complaints, failure to provide necessary care for activities of daily living, incomplete neurological assessments after falls, inadequate pressure injury prevention and treatment, insufficient fall prevention interventions, failure to provide appropriate respiratory care, and lack of required staff training on Quality Assurance and Performance Improvement (QAPI).
Deficiencies (10)
Failure to notify resident's representative of falls on 6/30/25 and 7/12/25.
Failure to timely report allegations of neglect, abuse, and misappropriation involving 7 residents to the State Survey Agency.
Failure to thoroughly investigate allegations of neglect, abuse, and misappropriation involving 7 residents.
Failure to provide necessary assistance with activities of daily living resulting in extremely long and dirty fingernails for one resident.
Failure to provide treatment and care in accordance with professional standards for 3 residents including incomplete neurological checks after falls, failure to follow physician orders for stool testing, and delayed hospital transfer after fall.
Failure to provide appropriate pressure ulcer care and prevention resulting in immediate jeopardy for one resident and ongoing deficiencies for another resident.
Failure to ensure adequate supervision and safety to prevent accidents for 3 residents including incomplete fall investigations and failure to implement fall interventions.
Failure to provide safe and appropriate respiratory care for a resident receiving oxygen therapy, including use of disconnected oxygen tubing and incorrect oxygen flow rate.
Failure to provide pharmaceutical services to meet the needs of a resident, resulting in missed doses of prescribed medication.
Failure to conduct mandatory Quality Assurance and Performance Improvement (QAPI) training for all direct care staff.
Report Facts
Residents affected: 7
Falls: 10
Braden Scale score: 18
Braden Scale score: 12
Medication doses missed: 3
Oxygen flow rate: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-N | Licensed Practical Nurse | Involved in fall assessment and care for resident R1 |
| NP-K | Nurse Practitioner | Assessed resident R1 after fall and delayed hospital transfer |
| DON-B | Director of Nursing | Interviewed regarding multiple deficiencies including fall investigations and pressure injury care |
| NHA-A | Nursing Home Administrator | Interviewed regarding staff training and overall facility compliance |
| PLC-J | Prior Life Coach | Conducted incomplete investigation of misappropriation allegation |
| LC-AA | Life Coach | Interviewed regarding grievance investigations and understanding of neglect/abuse |
| Pharmacy-S | Pharmacist | Interviewed regarding medication supply and administration for resident R2 |
| Pharmacy Manager-T | Pharmacy Manager | Interviewed regarding medication supply and administration for resident R2 |
| RN/NS-O | Registered Nurse/Nurse Supervisor | Interviewed regarding fall investigations and oxygen therapy |
| PTA-Y | Physical Therapy Assistant | First staff to find resident R1 after fall |
| CNA-I | Certified Nursing Assistant | Provided care for resident R1 and involved in fall investigation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and thoroughly investigate an injury of unknown origin (IUO) for one resident out of a sample of six.
Complaint Details
The complaint investigation found the facility failed to timely report and thoroughly investigate an injury of unknown origin for Resident 2, including failure to interview all staff with knowledge of the incident. The injury was a closed fracture of the right ankle with an undetermined age.
Findings
The facility failed to report an injury of unknown origin within required timeframes and did not thoroughly investigate the injury, as not all staff involved were interviewed. The injury was a closed fracture of the right ankle likely caused by improper transfer by staff, but this could not be verified.
Deficiencies (2)
Failed to timely report an injury of unknown origin to the State Survey Agency.
Failed to thoroughly investigate an injury of unknown origin; not all staff involved were interviewed.
Report Facts
Residents reviewed for abuse: 6
Residents with injury of unknown origin: 1
Days late reporting injury: 5
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Reported injury to Director of Nursing and documented resident's complaints |
| Director of Nursing | Director of Nursing | Received injury report, acknowledged late reporting and incomplete investigation |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 15, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide person-centered care planning, grievance resolution, care plan revisions, maintenance of residents' abilities, and timely provision of therapy services.
Complaint Details
The complaint investigation focused on issues including lack of resident participation in care planning, unresolved grievances filed by a resident's power of attorney, failure to revise care plans appropriately, inadequate assistance with activities of daily living, and delayed therapy services despite physician orders. The investigation substantiated these concerns with detailed findings from interviews, record reviews, and observations.
Findings
The facility failed to provide quarterly care conferences for a resident, did not promptly resolve grievances, did not revise care plans as needed, did not ensure residents maintained their abilities per care plans, and delayed initiation of therapy services despite physician orders.
Deficiencies (5)
Failure to allow resident to participate in the development and implementation of their person-centered plan of care.
Failure to honor the resident's right to voice grievances without discrimination or reprisal and to make prompt efforts to resolve grievances.
Failure to develop the complete care plan within 7 days of the comprehensive assessment and revise it based on resident needs, specifically regarding safe storage of dentures.
Failure to ensure residents do not lose the ability to perform activities of daily living unless medically indicated, including failure to assist resident with walking and toileting as per care plan.
Failure to provide or get specialized rehabilitative services in a timely manner as ordered by physician.
Report Facts
Deficiencies cited: 5
Care conference dates missed: 2
Grievances filed: 3
Therapy service delay: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LC-C | Life Coach | Named in findings related to failure to conduct care conferences and grievance investigations. |
| NHA-A | Nursing Home Administrator | Informed of concerns regarding care conferences, grievances, care plan revisions, resident assistance, and therapy delays. |
| DON-B | Director of Nursing | Informed of concerns regarding care conferences, grievances, care plan revisions, resident assistance, and therapy delays. |
| RN-N | Registered Nurse | Documented missing dentures and related progress notes. |
| FSD-L | Food Service Director | Interviewed regarding missing dentures grievance. |
| CNA-M | Certified Nursing Assistant | Interviewed regarding denture management and resident assistance. |
| CNA-D | Certified Nursing Assistant | Interviewed regarding resident transfer and mobility status. |
| COTA-G | Certified Occupational Therapy Assistant | Interviewed regarding communication of resident transfer status. |
| PT-H | Physical Therapist | Interviewed regarding therapy orders and resident functional status. |
| DOR-I | Director of Rehab | Interviewed regarding therapy order processing and delay. |
| NS-E | Nurse Supervisor | Interviewed regarding resident transfer status and documentation of refusals. |
Inspection Report
Routine
Census: 49
Deficiencies: 16
Date: Mar 3, 2025
Visit Reason
Routine inspection of Lindengrove Menomonee Falls nursing home to assess compliance with regulatory requirements including medication self-administration, resident preferences, care planning, pressure injury care, falls prevention, catheter care, dialysis services, medication monitoring, dietary services, infection control, staffing, and food service.
Findings
The facility had multiple deficiencies including failure to ensure proper medication self-administration assessments and physician orders, inadequate linen supply affecting resident preferences, incomplete baseline and comprehensive care plans, insufficient pressure injury assessment and care leading to immediate jeopardy, inadequate falls assessment and interventions, failure to monitor catheter output and oxygen tubing changes, incomplete dialysis communication records, inaccurate nurse staffing postings, improper food preparation and delivery practices, and lack of monitoring for side effects of psychotropic and anticoagulant medications.
Deficiencies (16)
Failure to ensure residents self-administer medications only after interdisciplinary assessment and physician order.
Linen shortage leading to residents not receiving preferred hospital gowns affecting comfort and dignity.
Failure to develop and implement baseline care plans within 48 hours of admission for residents R197 and R350.
Failure to develop comprehensive care plan for urinary continence after discontinuation of Foley catheter for resident R297.
Failure to provide treatment and care according to orders and resident preferences, including inadequate wound assessments and delayed hospital transfer for resident R297.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for residents R147 and R350, including lack of individualized care plans and assessments.
Failure to ensure adequate supervision and fall prevention interventions for residents R12, R23, R36, R39, R346, and R347.
Failure to monitor and document urinary catheter output as ordered for residents R23 and R346.
Failure to provide safe and appropriate respiratory care including weekly oxygen tubing changes for resident R23.
Failure to follow antibiotic stewardship program for resident R23, including treatment of UTI without meeting criteria.
Failure to provide food accommodations and preferences as listed on resident meal tickets for residents R196, R197, and R347.
Failure to ensure facility kitchen dish machine was functioning and monitored for sanitization; dietary staff observed without hair restraints; resident meal trays not covered during delivery.
Failure to designate a licensed nurse as charge nurse on each tour of duty.
Failure to have a registered nurse on duty for at least 8 consecutive hours a day, 7 days a week.
Failure to ensure daily nurse staff postings accurately reflected the correct number of staff members.
Failure to monitor for adverse reactions of psychotropic medications for residents R350, R3, and R36.
Report Facts
Facility census: 49
Gowns delivered: 50
Gowns ordered: 50
Gowns delivered: 200
Gowns not ordered: 0
Fall risk score: 15
Fall risk score: 13
Fall risk score: 10
Fall risk score: 13
Weight: 233
Weight: 189.5
Weight: 219.4
Weight: 200.2
Temperature: 102.8
Temperature: 102.9
Medication doses: 7
Oxygen liters: 2
Oxygen tubing date: Dec 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding baseline care plans, falls process, medication monitoring, pressure injury care, and staffing |
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Interviewed regarding staffing, dietary concerns, and pressure injury care |
| Licensed Practical Nurse (LPN)-H | Licensed Practical Nurse | Interviewed regarding resident R297 care and medication monitoring |
| Registered Nurse (RN)-I | Registered Nurse/Wound Nurse | Interviewed regarding wound care assessments and care plan updates |
| Registered Dietitian (RD)-DD | Registered Dietitian | Interviewed regarding dietary preferences and nutritional management |
| Facility Services Manager (FSM)-L | Facility Services Manager | Interviewed regarding linen supply and wheelchair cushion |
| Nursing Student-CCC | Nursing Student | Created UA order for resident R297 and involved in resident transfer |
| Licensed Practical Nurse (LPN)-H | Licensed Practical Nurse | Sent resident R297 to hospital and involved in medication monitoring |
| Certified Nursing Assistant (CNA)-K | Certified Nursing Assistant | Observed transferring resident R23 without gait belt |
| Certified Nursing Assistant (CNA)-FF | Certified Nursing Assistant | Observed delivering uncovered meal trays |
| Regional Food Service Director (RFSD)-Z | Regional Food Service Director | Interviewed regarding dietary services and meal tray delivery |
| Food Service Director (FSD)-W | Food Service Director | Interviewed regarding dietary services, hair restraints, and dish machine monitoring |
| Scheduler-HHH | Scheduler | Interviewed regarding nursing schedules and charge nurse designation |
Inspection Report
Routine
Census: 13
Deficiencies: 6
Date: Mar 3, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including care planning, treatment, pressure ulcer care, falls prevention, staffing, and food safety.
Findings
The facility was found deficient in developing comprehensive person-centered care plans, providing appropriate treatment and care, preventing and managing pressure ulcers, ensuring adequate supervision to prevent falls, designating charge nurses on each shift, and maintaining sanitary food preparation and service practices.
Deficiencies (6)
Failure to develop a comprehensive person-centered care plan after discontinuation of a Foley catheter for resident R297.
Failure to provide appropriate treatment and care according to orders and resident preferences, resulting in hospitalization and death of resident R297 due to sepsis from UTI.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for residents R147 and R350, including lack of comprehensive assessments, individualized care plans, and proper support surfaces.
Failure to ensure adequate supervision and assistance to prevent accidents and falls, and failure to thoroughly assess falls and implement fall interventions for residents R12, R23, R36, R39, R346, and R347.
Failure to designate a licensed nurse as charge nurse on each tour of duty on the nursing schedules.
Failure to ensure food was prepared and served in a sanitary manner, including failure to monitor dish machine sanitization, dietary staff not wearing hair restraints, and uncovered food items during meal tray delivery.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 49
Fall risk evaluation score: 15
Fall risk evaluation score: 13
Fall risk evaluation score: 10
Pressure ulcer measurement: 4.5
Pressure ulcer measurement: 3.5
Pressure ulcer measurement: 0.1
Pressure ulcer measurement: 4
Pressure ulcer measurement: 3.5
Pressure ulcer measurement: 3.6
Weight: 233
Weight: 189.5
Weight: 219.4
Weight: 200.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding care plan process, falls, and pressure injury management |
| Advanced Practice Nurse Prescriber-FFF | Advanced Practice Nurse Prescriber | Provided care and orders for resident R297 |
| Licensed Practical Nurse (LPN)-WW | Licensed Practical Nurse | Provided care and monitoring for resident R297 |
| Nursing Student-CCC | Nursing Student | Created order for urinalysis and provided care for resident R297 |
| Licensed Practical Nurse (LPN)-H | Licensed Practical Nurse | Provided care and documented falls and skin assessments |
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding falls and pressure injury management |
| Registered Nurse (RN)-I | Registered Nurse/Wound Nurse | Conducted weekly wound assessments with Wound Nurse Practitioner |
| Assistant Director of Nurses (ADON)-G | Assistant Director of Nurses | Provided wound care and interviewed about wheelchair cushion and air mattress |
| Registered Dietitian (RD)-DD | Registered Dietitian | Interviewed regarding nutritional management of resident R147 |
| Facility Service Manager (FSM)-L | Facility Service Manager | Provided manufacturer recommendations for wheelchair cushion |
| Scheduler-HHH | Scheduler | Interviewed regarding nursing schedules and charge nurse designation |
| Food Service Director (FSD)-W | Food Service Director | Provided policies and interviewed regarding food service and dish machine monitoring |
| Regional Food Service Director (RFSD)-Z | Regional Food Service Director | Interviewed regarding food service and dish machine monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 30, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide ordered post void residuals for Resident 2 and failure to provide timely and effective pain management for Resident 4.
Complaint Details
The complaint investigation revealed that Resident 2 did not receive post void residuals every shift as ordered, and Resident 4 experienced a delay of approximately 3.5 hours in receiving prescribed Oxycodone due to pharmacy communication and medication access issues. The Director of Nurses confirmed the failures and initiated an investigation.
Findings
The facility failed to perform post void residuals every shift as ordered for Resident 2, and failed to follow pain management policies resulting in Resident 4 experiencing severe pain and crying for 3.5 hours before receiving narcotic pain medication.
Deficiencies (2)
Failed to perform post void residual on Resident 2 every shift as ordered.
Failed to provide safe, appropriate pain management for Resident 4, resulting in prolonged severe pain and delayed administration of narcotic medication.
Report Facts
Post void residual documented: 1
Pain duration: 3.5
Medication doses: 8
Pain rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN3 | Licensed Practical Nurse | Reported delays in obtaining Oxycodone for Resident 4 and communication issues with pharmacy |
| RN1 | Registered Nurse | Interviewed regarding Resident 2's care and lack of post void residual completion |
| DON | Director of Nurses | Confirmed failure to transcribe physician order for post void residuals and initiated investigation into pain medication delay |
| NP | Nurse Practitioner | Ordered post void residuals for Resident 2 and commented on pain management expectations for Resident 4 |
| LPN1 | Licensed Practical Nurse | Administered Oxycodone to Resident 4 after delay and reported observations |
| LPN2 | Licensed Practical Nurse | Notified pharmacy for stat muscle relaxant for Resident 4 and communicated with NP |
| Pharmacy Facility Manager | Provided details on pharmacy procedures and communication regarding narcotic medication access | |
| CNA2 | Certified Nursing Assistant | Observed Resident 4 screaming in pain during admission |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 17, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents' medical needs, inadequate discharge planning, insufficient pressure injury prevention and care, incomplete fall investigations, improper medication storage and labeling, inadequate infection control surveillance and water management, improper disposal of garbage, and failure to offer pneumonia vaccines to some residents.
Deficiencies (8)
Failure to develop comprehensive care plans for assessed medical needs including anticoagulant use, diabetes, respiratory care, and elopement risk.
Failure to ensure resident R43 received a thorough discharge summary communicating necessary information at discharge.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents, including delayed assessments and lack of updated care plans.
Failure to conduct thorough fall investigations including root cause analysis and staff interviews for residents R43 and R39.
Failure to ensure medications including eye drops and insulin were dated when opened, expired medications were removed, medications of discharged residents were disposed, and medication refrigerator temperature was monitored.
Failure to properly dispose of garbage and maintain clean outside garbage receptacle area.
Failure to maintain documentation of a comprehensive infection control program including infection surveillance and water management plan.
Failure to offer pneumonia vaccine to two residents and document vaccine offers and refusals.
Report Facts
Residents reviewed for pressure injuries: 8
Residents reviewed for falls: 6
Residents reviewed for vaccinations: 5
Residents affected by medication labeling/storage issues: 4
Residents affected by pressure injury deficiencies: 5
Residents affected by fall investigation deficiencies: 2
Residents affected by vaccination deficiencies: 2
Residents affected by infection control deficiencies: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lachiquita [NAME] | Director of Nursing | Interviewed regarding care plan expectations and fall investigations. |
| Administrator-A | Nursing Home Administrator | Participated in exit meetings and was informed of multiple deficiencies. |
| DON-B | Director of Nursing | Interviewed multiple times regarding care plans, fall investigations, pressure injury care, and infection control. |
| MDS RN-C | Minimum Data Set Registered Nurse Coordinator | Interviewed regarding care plan development responsibilities. |
| LPN-O | Licensed Practical Nurse | Interviewed regarding medication labeling and expiration. |
| LPN-L | Licensed Practical Nurse | Interviewed regarding medication storage and fall investigations. |
| CNC-F | Clinical Nurse Consultant | Interviewed regarding infection control program and vaccination documentation. |
| LPN-E | Licensed Practical Nurse | Interviewed regarding fall investigations and infection control. |
| Maintenance Lead-H | Maintenance Lead | Interviewed regarding water management and dumpster area maintenance. |
| Head Chef-I | Head Chef | Interviewed regarding dumpster maintenance. |
| Social Services-P | Social Services | Interviewed regarding discharge summary expectations. |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to comprehensive care planning, discharge planning, pressure ulcer care, fall investigations, and infection control.
Findings
The facility failed to develop comprehensive care plans for multiple residents' assessed medical needs, did not provide a discharge summary for a discharged resident, failed to provide appropriate pressure ulcer care and prevention for several residents, did not thoroughly investigate resident falls, and lacked a comprehensive infection prevention and control program including infection surveillance and a water management plan.
Deficiencies (5)
Failure to develop comprehensive care plans for assessed medical needs for 5 of 21 residents reviewed.
Failure to ensure necessary information is communicated to the resident and receiving health care provider at the time of planned discharge for 1 of 7 residents reviewed.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for 5 of 8 residents reviewed, including delayed assessment and lack of care plan updates.
Failure to conduct thorough fall investigations including root cause analysis and staff interviews for 2 of 6 residents reviewed.
Failure to maintain documentation of a comprehensive infection control program including infection surveillance and lack of a comprehensive water management plan.
Report Facts
Residents reviewed for care planning: 21
Residents affected by care planning deficiency: 5
Residents reviewed for discharge planning: 7
Residents affected by discharge planning deficiency: 1
Residents reviewed for pressure injuries: 8
Residents affected by pressure injury deficiency: 5
Residents reviewed for falls: 6
Residents affected by fall investigation deficiency: 2
Residents in facility: 38
Covid positive cases in outbreak: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lachiquita [REDACTED] | Director of Nursing | Interviewed regarding care plan expectations and fall investigations |
| Administrator-A | Nursing Home Administrator | Participated in exit meetings and was informed of deficiencies |
| DON-B | Director of Nursing | Interviewed regarding care plans, fall investigations, and infection control |
| MDS RN-C | Minimum Data Set Registered Nurse Coordinator | Interviewed regarding care plan development responsibilities |
| CNC-F | Clinical Nurse Consultant | Interviewed regarding infection control program and survey findings |
| CNC-G | Clinical Nurse Consultant | Participated in exit meetings |
| LPN-E | Licensed Practical Nurse | Interviewed regarding fall investigations and infection control |
| LPN-L | Licensed Practical Nurse | Interviewed regarding fall policy and resident fall |
| MN-H | Maintenance Lead | Interviewed regarding water management plan |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 7, 2023
Visit Reason
The inspection was conducted to assess compliance with federal and state regulations regarding timely reporting of suspected abuse, quality of care, pressure ulcer care, infection prevention, and behavioral health training in the nursing home.
Findings
The facility was found deficient in timely reporting of suspected diversion of controlled medication, consistent assessment of residents' medical stability, timely assessment and treatment of pressure injuries, designation of a qualified infection preventionist, and provision of behavioral health training to certified nurse aides.
Deficiencies (5)
Failed to ensure timely reporting of potential misappropriation of controlled medication for one resident.
Failed to ensure one resident was appropriately and consistently assessed to ensure overall medical stability, specifically blood pressure monitoring prior to stroke.
Failed to ensure timely assessment and treatment of pressure injuries for one resident, resulting in worsened pressure areas and a large terminal ulcer upon discharge.
Failed to designate a qualified Infection Preventionist with specialized training working at least part time after 1/6/23.
Failed to provide behavioral health training consistent with facility assessment requirements to three Certified Nurse Aides.
Report Facts
Residents reviewed for narcotics and potential diversion: 14
Residents reviewed for quality of care: 18
Residents reviewed for pressure injuries: 3
Residents affected by infection preventionist deficiency: 89
Certified Nurse Aides reviewed for behavioral health training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator-A | Administrator | Confirmed medication diversion and lack of reporting to State Department of Health |
| Interim Director of Nursing B | Interim Director of Nursing | Confirmed expectation for reporting medication diversion and timely vital sign assessments |
| Previous Interim Director of Nursing C | Interim Director of Nursing | Responsible for investigation of medication diversion and confirmed substantiation |
| Staffing Coordinator-T | Staffing Coordinator | Confirmed lack of behavioral health training for CNAs |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 15, 2022
Visit Reason
The inspection was conducted due to concerns regarding pressure ulcer care and medication error rates at the facility.
Complaint Details
The complaint investigation found substantiated deficiencies related to pressure ulcer care and medication errors, affecting a few residents.
Findings
The facility failed to ensure appropriate pressure ulcer care for a resident with a stage III pressure injury, delaying the initiation of an appropriate pressure reducing mattress. Additionally, the facility had a medication error rate of 7.14%, with errors including failure to administer ordered eye drops and administration of expired insulin.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with a stage III pressure injury.
Medication error rate exceeded 5 percent, including failure to administer ordered eye drops and administration of expired insulin.
Report Facts
Medication error rate: 7.14
Pressure injury measurement: 1
Pressure injury measurement: 1.7
Pressure injury measurement: 1
Pressure injury measurement: 0.2
Braden skin risk score: 14
BIMS score: 11
Medication errors: 2
Medication opportunities: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Program Director-E | Program Director | Reported responsibility for creating and initiating care plans; provided mattress specifications; acknowledged delay in mattress initiation |
| RN-H | Registered Nurse | Reported admissions nurse role and care plan collaboration |
| RN-F | Registered Nurse | Admissions nurse; described skin check and treatment initiation process |
| Admissions Coordinator-G | Admissions Coordinator | Explained mattress management and room assignment for bariatric residents |
| Nursing Home Administrator-A | Nursing Home Administrator | Informed of concerns regarding mattress and medication errors |
| Medication Technician-D | Medication Technician | Observed preparing and administering medications; involved in medication error observation |
| Registered Nurse-C | Registered Nurse | Observed administering expired insulin |
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