Inspection Reports for Menomonee Falls Health Services

The facility failed to ensure that one resident (R1) was properly assessed and authorized to self-administer medications. Medications were left at the bedside without clinical approval, resulting in delayed administration and potential risk to the resident.

The facility was found deficient in multiple areas including incomplete criminal background checks for staff, failure to provide written transfer and bed hold notices to residents and representatives, inaccurate MDS assessments for several residents, inadequate pressure ulcer care and staging, insufficient supervision leading to resident accidents, improper medication labeling and storage, lack of timely hospice documentation, lapses in infection prevention practices including PPE use and water management, and incomplete documentation of immunization offers and refusals.

The complaint investigation focused on notification failures to resident R5's HCPOA regarding new wounds, inadequate pressure injury care, failure to provide assistive devices, and incomplete medication administration documentation for residents R1 and R3.

The facility failed to notify the health care power of attorney (HCPOA) of new wounds for resident R5, did not provide care and treatment consistent with professional standards for pressure injuries, failed to ensure assistive devices such as hearing aids and glasses were used, and had incomplete and inaccurate medication administration records for residents R1 and R3. Additionally, the facility did not implement timely wound care orders or update care plans appropriately.

The facility failed to provide a safe, clean, and comfortable environment, as evidenced by residents being served meals on trays in the dining room and the presence of strong urine odors and yellow stains on residents' bedding in multiple rooms.

The complaint investigation focused on allegations that the facility did not ensure residents at risk for pressure injuries were comprehensively assessed and provided individualized care plans, including repositioning schedules and pressure relief interventions. It also addressed concerns about inadequate foot care and diabetic foot checks for a resident with diabetes. The investigation found substantiated deficiencies related to these issues.

The facility failed to provide appropriate pressure ulcer care and foot care, did not ensure individualized care plans were updated or followed for residents at risk for pressure injuries, and did not consistently perform required diabetic foot checks. Two residents (R1 and R2) were found to have pressure injuries with inadequate care planning and treatment adherence.

The complaint investigation involved allegations from residents R21, R39, R41, R18, and R86 regarding abuse, neglect, failure to report incidents, and inadequate investigations. Some allegations were unsubstantiated due to lack of evidence or incomplete investigations. The facility failed to report incidents within required timeframes and did not complete thorough investigations for multiple residents.

The facility failed to timely report suspected abuse, neglect, or injury of unknown origin to proper authorities for several residents. Investigations were incomplete, delayed, or not conducted for multiple allegations. Staff failed to follow facility policies regarding abuse reporting and investigation procedures.

The facility failed to ensure that 1 of 24 staff members, specifically a Certified Nursing Assistant, was fully vaccinated for COVID-19, despite having a policy to ensure all eligible employees are vaccinated according to federal, state, and local guidelines.