Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 1
Jun 13, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical service requirements, specifically to verify that narcotic counts were properly initialed by two nurses on all three shifts at the change of shift to ensure accuracy and prevent drug diversion.
Findings
The facility failed to ensure that narcotic counts were initialed by two nurses on all three shifts for six medication carts reviewed, with multiple instances of missing signatures on narcotic count sheets across various dates. This failure posed a potential risk for drug diversion.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure narcotic counts were initialed by two nurses on all three shifts for six medication carts reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication carts reviewed: 6
Dates with missing narcotic count signatures: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Verified narcotic count sheet was not signed on each shift for the 500 South cart. |
| LPN2 | Licensed Practical Nurse | Verified narcotic count sheet was not signed on each shift for the 500 North cart. |
| LPN5 | Licensed Practical Nurse | Verified narcotic count sheet for the 400 North cart was not signed off by two nurses on each shift. |
| LPN4 | Licensed Practical Nurse | Verified narcotic count sheet for the 400 South cart was not signed off by two nurses on each shift. |
| LPN1 | Licensed Practical Nurse | Confirmed narcotic sheet for the 300 North cart was not signed by each nurse. |
| LPN3 | Licensed Practical Nurse | Confirmed narcotic count sheet for the 300 South cart had not been signed on each shift. |
| Director of Nursing | Director of Nursing | Confirmed narcotic sheets were not signed off on each shift and stated nurses were supposed to sign sheets during shift change. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Jan 21, 2025
Visit Reason
The inspection was conducted to investigate complaints related to psychotropic medication management, food safety and storage, hospice service communication, and infection control practices at the Jewish Home and Care Center.
Findings
The facility was found deficient in multiple areas including failure to limit PRN psychotropic medication orders to 14 days, expired consents and incomplete assessments for residents on psychotropic drugs, improper food storage and lack of hair restraints in the kitchen, inadequate communication and documentation of hospice services for residents, and failure to ensure all staff received annual N95 respirator fit testing.
Complaint Details
The investigation was complaint-driven focusing on psychotropic medication management, food safety, hospice service communication, and infection control practices. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to limit PRN psychotropic medication orders to 14 days for residents R23, R18, and R9. | Level of Harm - Minimal harm or potential for actual harm |
| Expired consent and incomplete quarterly sleep assessments for resident R23 on Trazodone. | Level of Harm - Minimal harm or potential for actual harm |
| Lack of stop dates on PRN psychotropic medication orders for residents R18 and R9. | Level of Harm - Minimal harm or potential for actual harm |
| Improper food storage including undated and open food items, and lack of hair restraints for kitchen staff. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate communication and documentation of hospice services for residents R9 and R43, including missing hospice election statements, care plans, and visit documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure 34 staff received annual N95 respirator fit testing, with many staff overdue or missing fit test documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for psychotropic medications: 7
Residents affected by psychotropic medication deficiencies: 3
Residents affected by food safety deficiencies: 74
Residents affected by hospice communication deficiencies: 2
Staff overdue for N95 fit testing: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed regarding psychotropic medication PRN orders, hospice communication, and infection control program. |
| NHA-A | Nursing Home Administrator | Interviewed regarding psychotropic medication PRN orders, hospice communication, and infection control program. |
| Kitchen Manager-C | Interviewed regarding food storage and hair restraint issues in the kitchen. | |
| Social Worker-I | Interviewed regarding expired consent for resident R23's Trazodone. | |
| RN Unit Manager-E | Registered Nurse Unit Manager | Interviewed regarding sleep assessments for resident R23 and hospice communication. |
| LPN-K | Licensed Practical Nurse | Interviewed regarding hospice services communication for resident R43. |
| HIC-F | Health Information Clerk | Interviewed regarding hospice documentation for resident R43. |
| HIC-G | Health Information Clerk | Interviewed regarding hospice documentation for resident R9. |
| Cook-D | Observed not wearing hair or beard restraints in the kitchen. | |
| IP-L | Infection Preventionist | Interviewed regarding infection control program and staff fit testing. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 6, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to administer medications as ordered, specifically that Resident 1 (R1) did not receive the correct dosage of Hydrocodone-Acetaminophen prior to dialysis on 10/2/24.
Findings
The facility failed to ensure that R1 received two tablets of Hydrocodone-Acetaminophen 5-325 mg prior to dialysis on 10/2/24, administering only one tablet instead. This was due to staff misreading the physician's orders, resulting in minimal harm or potential for actual harm to the resident.
Complaint Details
The complaint investigation confirmed that on 10/2/24, R1 did not receive the second dose of his pain medication before going to dialysis. The resident representative reported this, and interviews with nursing staff revealed a misinterpretation of medication orders. The deficiency was substantiated with minimal harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically administering only one tablet of Hydrocodone-Acetaminophen instead of two prior to dialysis. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Pain intensity score: 8
BIMS score: 13
Date of incident: Oct 2, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN-D) | Nurse who administered only one tablet and refused second dose to Resident 1 on 10/2/24 | |
| Licensed Practical Nurse (LPN-E) | Supervisor who reviewed medication orders and informed nurse that Resident 1 could not have another Hydrocodone | |
| Registered Nurse Manager (RN Manager-F) | Acknowledged misreading the order and confirmed Resident 1 should have received two tablets | |
| Director of Nursing (DON-B) | Discussed the incident and confirmed the medication error occurred due to misunderstanding of orders | |
| Nursing Home Administrator (NHA-A) | Informed of the medication administration issue on 11/6/24 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 22, 2024
Visit Reason
The inspection was conducted due to concerns about medication errors at the Jewish Home and Care Center, specifically regarding significant medication errors involving resident R2.
Findings
The facility failed to ensure that resident R2 was free from significant medication errors, including administration of Morphine not prescribed to R2 and a double dose of Clonazepam. The errors resulted in actual harm requiring close monitoring of vital signs and neurological status. The facility's policies on medication administration and error reporting were not fully followed, and training for agency staff was inadequate.
Complaint Details
The investigation was complaint-related, focusing on medication errors involving resident R2. The errors were substantiated, with documentation of actual harm and insufficient monitoring and training following the errors.
Severity Breakdown
Level of Harm - Actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Resident R2 received Morphine on 05/26/2024, which was not prescribed and required close monitoring of physiological status. | Level of Harm - Actual harm |
| Resident R2 received a double dose of Clonazepam (1 mg instead of 0.5 mg) on 05/21/2024. | Level of Harm - Actual harm |
Report Facts
Medication error dates: 2
Vital sign monitoring frequency: 12
Vital sign monitoring duration: 72
Medication doses: 1
Fluid order: 480
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| UM-D | Unit Manager | Interviewed regarding medication errors and monitoring of resident R2. |
| LPN-C | Licensed Practical Nurse | Made the medication error administering Morphine instead of Clonazepam to resident R2. |
| NHA-A | Nursing Home Administrator | Provided information on training and orientation policies and documentation related to medication errors. |
| DON-B | Director of Nursing | Discussed medication error reporting and staff training requirements. |
| RN-F | Registered Nurse | Interviewed about training and education following medication errors. |
| UM-E | Unit Manager | Described monitoring procedures following medication errors. |
Inspection Report
Routine
Deficiencies: 7
Oct 26, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of the Jewish Home and Care Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to promptly consult physicians on significant resident condition changes, inadequate implementation of restorative nursing programs, insufficient supervision and investigation related to resident falls, failure to adequately address nutritional needs and hydration status of residents, failure to follow posted menus and meet nutritional needs for alternative diet textures, unsanitary conditions in the main kitchen and unit kitchenettes, and incomplete implementation of the water management plan.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Level of Harm - Actual harm: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure staff promptly consulted with a physician when residents experienced significant changes of condition, specifically for a resident with consistently high blood pressure after a fall. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care to maintain or improve range of motion and mobility for a resident, including failure to implement restorative nursing program recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and assistance to prevent accidents and to properly investigate falls, including lack of bowel and bladder assessments to determine toileting needs. | Level of Harm - Actual harm |
| Failure to recognize, evaluate, and address nutritional care needs to provide adequate nutritional status, including failure to monitor significant weight loss and dehydration in a resident. | Level of Harm - Actual harm |
| Failure to follow posted menus and meet nutritional needs of residents requiring alternative diet textures, including serving unlisted food items and lack of proper labeling. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, and serve food in accordance with professional standards, including unsanitary conditions in the main kitchen and unit kitchenettes, presence of expired and unlabeled food items, and lack of adherence to cleaning schedules. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement an effective infection prevention and control program related to water management, including incomplete water management plan, lack of documentation for inspections, and inadequate flushing of closed unit water systems. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss: 17.5
Fluid intake: 230
Weight loss: 11.5
Weight loss: 16.5
Fall risk score: 65
BIMS score: 0
BIMS score: 2
Fluid intake: 720
Fluid intake: 100
Fluid intake: 400
Fluid intake: 360
Fluid intake: 960
Fluid intake: 1020
Fluid intake: 600
Fluid intake: 700
Fluid intake: 1200
Fluid intake: 640
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-O | Licensed Practical Nurse | Named in finding related to failure to notify physician of resident's high blood pressure after fall. |
| RN-F | Registered Nurse | Named in finding related to communication about resident's fall and blood pressure monitoring. |
| MD-P | Medical Director | Named in finding related to resident's high blood pressure and communication with nursing staff. |
| Therapy Director-D | Therapy Director | Named in finding related to restorative nursing program implementation for resident R17. |
| Physical Therapy Assistant-L | Physical Therapy Assistant | Named in finding related to restorative nursing program implementation for resident R17. |
| Physical Therapist-M | Physical Therapist | Named in finding related to restorative nursing program implementation for resident R17. |
| DON-B | Director of Nursing | Named in findings related to resident falls and nutritional care. |
| QI Coordinator-I | Quality Improvement Coordinator | Named in findings related to resident falls and toileting needs. |
| RD-Q | Registered Dietician | Named in findings related to nutritional assessment and care for resident R55. |
| AD-R | Assistant Dietician | Named in findings related to nutritional assessment and care for resident R55. |
| SLP-S | Speech Language Pathologist | Named in findings related to swallowing precautions and feeding assistance for resident R55. |
| DFS-C | Director of Food Services | Named in findings related to food service and kitchen sanitation. |
| PM-Y | Plant Operations Manager | Named in findings related to water management plan and inspections. |
| NHA-A | Nursing Home Administrator | Named in findings related to water management plan and nutritional care. |
Inspection Report
Deficiencies: 0
Aug 3, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the Jewish Home and Care Center, summarizing the results of a regulatory survey completed on 08/03/2022.
Findings
No health deficiencies were found during the inspection.
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