Deficiencies (last 3 years)
Deficiencies (over 3 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 16, 2025
Visit Reason
The inspection was conducted due to concerns about inadequate supervision to address wandering behavior and related safety issues involving residents entering others' rooms uninvited.
Complaint Details
The investigation was complaint-driven based on concerns from residents and their representatives about resident R32 wandering into other residents' rooms uninvited and causing distress. Interviews with residents, representatives, and staff confirmed these concerns and revealed inadequate supervision and communication.
Findings
The facility failed to ensure appropriate supervision and interventions to prevent resident R32 from wandering into other residents' rooms, causing distress. Additionally, the facility did not maintain an effective infection prevention and control program during a gastrointestinal outbreak, including failure to track staff illness symptoms and improper use of personal protective equipment (PPE) by staff.
Deficiencies (3)
Failure to provide adequate supervision or implement interventions to prevent resident R32 from entering other residents' rooms.
Failure to establish and maintain an infection prevention and control program, including not tracking last symptoms of illness and return to work dates for staff during a gastrointestinal outbreak.
Staff did not wear required PPE (gown, gloves, goggles) during care for residents on enhanced barrier precautions and failed to perform hand hygiene appropriately.
Report Facts
Residents affected: 3
Residents affected: 4
Residents affected: 88
Staff with missing symptom tracking: 3
Dates of GI outbreak: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON)-B | Director of Nursing | Provided policy and interview regarding wandering behavior and infection control |
| Certified Nursing Assistant (CNA)-H | Certified Nursing Assistant | Interviewed about resident R32's wandering and behavior |
| Registered Nurse (RN)-J | Registered Nurse | Interviewed about resident R32's wandering and redirection |
| Unit Manager (UM)-I | Unit Manager | Interviewed about supervision and resident concerns regarding wandering |
| Infection Preventionist (IP)-C | Infection Preventionist | Interviewed about infection control policies and staff symptom tracking |
| Licensed Practical Nurse (LPN)-F | Licensed Practical Nurse | Observed and interviewed regarding improper PPE use and hand hygiene |
| Registered Nurse (RN)-G | Registered Nurse | Observed and interviewed regarding improper PPE use during wound care |
| Certified Nursing Assistant (CNA)-D | Certified Nursing Assistant | Staff with missing symptom tracking during GI outbreak |
| Certified Nursing Assistant (CNA)-E | Certified Nursing Assistant | Staff with missing symptom tracking during GI outbreak |
| Certified Nursing Assistant (CNA)-K | Certified Nursing Assistant | Interviewed about resident R32's wandering behavior |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety standards, specifically to verify that dishwasher temperatures were monitored and recorded to ensure proper sanitization of dishware across all neighborhoods in the facility.
Findings
The facility failed to ensure dishwasher temperatures were monitored and documented daily on all five neighborhoods, with multiple missing temperature logs noted from March through August 2024. Interviews confirmed staff responsibility for monitoring and documenting temperatures, but logs were incomplete.
Deficiencies (1)
Dishwasher temperatures were not monitored or documented daily on all 5 neighborhoods in the facility.
Report Facts
Missing temperature log entries: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-D | Certified Nursing Assistant | Interviewed regarding dishwasher temperature logs and responsibility for monitoring and documenting temperatures |
| UA-C | Unit Assistant | Interviewed regarding responsibility for checking dishwasher temperature logs and reporting incomplete logs to Unit Manager |
| NHA-A | Nursing Home Administrator | Interviewed and verified staff responsibility to monitor and document dishwasher temperatures daily |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 6, 2024
Visit Reason
The inspection was conducted as a standard annual survey of Park View Health Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 1
Date: Sep 12, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically focusing on hand hygiene during care provision.
Findings
The facility failed to ensure proper hand hygiene by staff during care for one resident, as observed when a Certified Nursing Assistant did not perform hand hygiene at required times during perineal care and related tasks.
Deficiencies (1)
Failure to perform appropriate hand hygiene during provision of care for one resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-C | Certified Nursing Assistant | Observed not performing proper hand hygiene during resident care. |
| DON-B | Director of Nursing | Interviewed regarding hand hygiene expectations and confirmed facility standards. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 15, 2023
Visit Reason
The inspection was conducted based on complaint-related concerns regarding behavioral health care, food safety, and immunization documentation at Park View Health Center.
Complaint Details
The complaint investigation focused on behavioral health care following a resident's suicidal ideation statement, food safety practices including dishwasher temperature and food dating, and influenza immunization documentation for selected residents.
Findings
The facility failed to ensure proper behavioral health care following a resident's suicidal ideation statement, did not maintain sanitary food storage and preparation practices including dishwasher temperature monitoring and food date marking, and lacked proper documentation of influenza immunizations for several residents.
Deficiencies (3)
Facility did not ensure assessments, interventions, and increased monitoring after a resident verbalized suicidal ideation; staff failed to update the interdisciplinary team and inform psychologist/psychiatrist.
Facility did not ensure food was stored and served under sanitary conditions; dishwasher internal surface temperature monitoring device failed to reach required 160°F since July 2022; foods and beverages were not dated upon opening and outdated items were not discarded.
Facility did not ensure medical records contained documentation related to influenza immunizations for 3 residents reviewed.
Report Facts
Residents affected: 5
Residents affected: 94
Residents affected: 3
Dishwasher temperature: 160
Dishwasher temperature failure start date: 202207
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-I | Licensed Practical Nurse | Documented resident's suicidal ideation but did not update interdisciplinary team |
| SW-F | Social Worker | Interviewed regarding suicidal ideation statement; denied awareness of statement |
| RN-G | Registered Nurse | Interviewed regarding suicidal ideation statement; denied prior awareness |
| DM-H | Dietary Manager | Interviewed and verified food safety deficiencies including dishwasher temperature and food dating |
| IP-C | Registered Nurse Manager/Quality Assurance & Infection Control | Interviewed regarding influenza immunization documentation and provided additional information |
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