Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% better than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding physical abuse of a resident by a staff member.
Complaint Details
The complaint investigation substantiated that a Certified Nursing Assistant (CNA C) physically abused resident R1 by striking her in the face. The incident was witnessed by another CNA (CNA D). The alleged abuser was arrested and removed from the facility. Immediate jeopardy was identified on 01/06/25 and removed on 01/07/25 after corrective actions including staff education and resident assessments were completed.
Findings
The facility failed to protect a resident from physical abuse by a staff member and did not immediately protect the resident after the abuse occurred. Immediate jeopardy was identified but removed after staff education and corrective actions were implemented.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. A staff member struck a resident in the face and left the resident alone with the alleged abuser for approximately 15 minutes, placing the resident at risk for further harm.
Report Facts
Residents reviewed for abuse: 4
Residents affected: 1
Date immediate jeopardy began: Jan 6, 2025
Date immediate jeopardy removed: Jan 7, 2025
Date immediate jeopardy corrected: Jan 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Witnessed the abuse and reported the incident |
| CNA C | Certified Nursing Assistant | Perpetrator who struck resident R1 |
| RN E | Registered Nurse | Informed of the incident, reported to administration and police, and assisted with investigation |
| CNA F | Certified Nursing Assistant | Assisted during investigation and stayed with CNA C after incident |
| NHA A | Nursing Home Administrator | Notified of immediate jeopardy |
| DON B | Director of Nursing | Notified of immediate jeopardy and involved in staff education |
Inspection Report
Routine
Deficiencies: 3
Date: Aug 29, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with professional standards of care, infection control, food safety, and prevention of pressure injuries in a nursing home facility.
Findings
The facility failed to provide appropriate pressure ulcer care and prevention, did not follow professional standards for food service safety, and did not maintain an effective infection prevention and control program during a COVID-19 outbreak. Multiple residents were observed not being repositioned as required, staff improperly handled food with contaminated gloves, and PPE use was inconsistent with CDC guidance.
Deficiencies (3)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing. Residents R58, R89, R9, and R28 were not repositioned as required, leading to worsening or new pressure injuries.
F 0812: The facility did not prepare, distribute, and serve food in accordance with professional standards. Staff touched ready-to-eat foods with contaminated gloves and carried uncovered food trays in hallways.
F 0880: The facility failed to maintain an infection prevention and control program. Staff did not consistently follow CDC PPE guidance during a COVID-19 outbreak, including improper mask use, lack of eye protection, and inadequate hand hygiene between glove changes.
Report Facts
Residents affected: 4
Residents affected: 18
Braden risk assessment scores: 11
Braden risk assessment scores: 14
Braden risk assessment scores: 15
Braden risk assessment scores: 13
Pressure injury measurements: 3.6
Pressure injury measurements: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN S | Licensed Practical Nurse | Interviewed about pressure injury care and PPE use during COVID-19 outbreak |
| CNA O | Certified Nursing Assistant | Observed improperly handling food and PPE use during COVID-19 outbreak |
| CNA G | Certified Nursing Assistant | Observed not using appropriate PPE when caring for resident on contact precautions |
| RN E | Registered Nurse, Infection Preventionist | Interviewed about infection control practices and PPE use |
| DON B | Director of Nursing | Interviewed about repositioning policies and pressure injury prevention |
| CSM D | Culinary Services Manager | Interviewed about food handling practices |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident privacy, medication management, infection control, and drug regimen appropriateness.
Findings
The facility was found to have multiple deficiencies including failure to maintain confidentiality of resident medical records, improper monitoring of prophylactic antibiotic use, unsecured medication carts, and inadequate hand hygiene practices by staff.
Deficiencies (4)
F 0583: The facility did not maintain confidentiality of resident medical record information for 12 of 12 sampled residents. Resident dietary information was displayed on tables and medication cart computer screens were left unattended with resident information visible.
F 0757: The facility did not ensure each resident's drug regimen was free from unnecessary drugs. One resident was on a prophylactic antibiotic for an excessive duration without adequate monitoring or care plan.
F 0761: The facility did not ensure all drugs and biologicals were stored in locked compartments and did not restrict key access to authorized personnel. Medication carts were observed unlocked with keys and medications left unattended.
F 0880: Staff did not perform hand hygiene when warranted during cares for 3 of 7 residents observed. Certified Nursing Assistants failed to perform hand hygiene before glove use and between clean and dirty tasks.
Report Facts
Residents affected: 12
Residents affected: 1
Medication carts observed: 6
Residents observed for hand hygiene: 7
Residents with hand hygiene issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing B | Director of Nursing | Interviewed regarding prophylactic antibiotic use, medication cart security, and hand hygiene observations |
| Nurse Tech F | Nurse Technician | Observed leaving medication cart unattended with resident information visible and unlocked cart |
| Dietary Aide G | Dietary Aide | Interviewed about placing resident dietary information on tables |
| Food Service Director H | Food Service Director | Interviewed about dietary ticket process and privacy concerns |
| Licensed Practical Nurse C | Licensed Practical Nurse | Observed leaving resident medication information visible on computer screen |
| Certified Nursing Assistant I | Certified Nursing Assistant | Observed failing to perform hand hygiene during resident cares |
| Certified Nursing Assistant J | Certified Nursing Assistant | Observed failing to perform hand hygiene during resident cares |
| Certified Nursing Assistant D | Certified Nursing Assistant | Observed failing to perform hand hygiene before catheter care |
| Certified Nursing Assistant Q | Certified Nursing Assistant | Observed failing to perform hand hygiene before glove use and touching own hair |
| Certified Nursing Assistant E | Certified Nursing Assistant | Observed failing to perform hand hygiene before glove use |
Inspection Report
Census: 100
Deficiencies: 1
Date: Jun 9, 2022
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation standards in the facility's kitchen and food storage areas.
Findings
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, with multiple instances of expired food items, uncovered leftovers, undated opened milk containers, dirty freezer shelves, and improper food handling practices observed.
Deficiencies (1)
F 0812: The facility did not procure food from approved sources or maintain proper storage, preparation, and distribution standards. Expired buttermilk, uncovered leftovers, undated and expired milk and juice products, dirty freezer shelves, and improper food handling without gloves or hand hygiene were observed.
Report Facts
Residents Affected: 100
Expired buttermilk: 4
Uncovered leftovers: 17
Uncovered ice cream dishes: 10
Uncovered applesauce dishes: 35
Expired mighty shakes: 6
Expired cranberry juice boxes: 3
Undated opened milk containers: 7
Leftover pans incorrectly dated: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E | Cook/Supervisor | Observed and discussed food storage and handling practices during kitchen walkthrough |
| C | Dietary Manager | Interviewed regarding food dating responsibilities and sanitation expectations |
| H | Licensed Practical Nurse | Interviewed about milk expiration and dating responsibilities |
| D F | Dietary Aide | Observed handling food without gloves and discussed milk expiration dating |
| C S D | Cook/Supervisor | Observed serving food without gloves and improper hand hygiene |
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