Deficiencies (last 4 years)
Deficiencies (over 4 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
270% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 4
May 29, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, failure to timely report suspected abuse, neglect or theft, failure to respond appropriately to alleged violations, and failure to revise care plans after changes in resident status.
Findings
The facility failed to protect residents from resident-to-resident abuse involving multiple residents, failed to timely report abuse allegations to the State Agency and law enforcement, did not conduct thorough investigations of abuse allegations, and failed to revise a resident's care plan after a change in medication self-administration status. Several incidents of verbal and physical abuse were documented, and staff actions were found inadequate in preventing or addressing these issues.
Complaint Details
The complaint investigation involved allegations of resident-to-resident abuse involving residents R1, R6, R7, R8, R11, R12, R19, and others. Specific incidents included inappropriate touching, verbal threats of sexual assault, physical altercations, and verbal abuse by staff. The facility failed to timely report some allegations to the State Agency and law enforcement. Investigations were incomplete or delayed, and police were not contacted in some cases because residents declined to press charges. The facility also failed to revise care plans appropriately after changes in resident status.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to protect residents from resident-to-resident abuse for five residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to respond appropriately to all alleged violations and complete thorough investigations for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop the complete care plan within 7 days of the comprehensive assessment and revise the care plan for one resident after a change in medication self-administration status. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 3
Residents affected: 1
Cash amount: 58
BIMS scores: 1
BIMS scores: 3
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Intervened during verbal abuse incident involving CNA1 and resident R11; escorted CNA1 out of the facility |
| CNA1 | Certified Nurse Aide | Agency CNA involved in verbal abuse incident with resident R11; removed from facility |
| Administrator | Interviewed regarding multiple abuse incidents, reporting failures, and investigation deficiencies | |
| Director of Nursing | DON | Interviewed regarding abuse incidents, reporting failures, investigation deficiencies, and care plan revision failures |
Inspection Report
Routine
Deficiencies: 7
Nov 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including care planning, activities of daily living assistance, pressure ulcer care, feeding tube care, medication availability, food palatability, and infection prevention.
Findings
The facility was found deficient in multiple areas including failure to provide sufficient notice to family for care conferences, inadequate nail care, delayed pressure ulcer treatment orders and administration, improper feeding tube care and labeling, medication availability issues causing pain and infection risk, serving food at inappropriate temperatures, and infection control lapses related to pressure ulcer treatment supplies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to inform a family member of care conferences and/or provide sufficient notice in advance for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nail care to one resident resulting in unmet personal hygiene needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pressure ulcer treatments were ordered and provided timely for two residents, putting them at risk for deterioration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care and services for feeding tube for one resident, including lack of labeling and inconsistent site assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were available for administration for two residents, resulting in uncontrolled pain and delayed antibiotic treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve food at an appetizing temperature for one resident, potentially causing unmet nutritional needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to perform pressure ulcer treatments in a manner to prevent potential cross contamination for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 13
Care conference date: 2024
BIMS score: 15
Nail length: 0.5
Pressure ulcer treatment order date: 2024
Delay in antibiotic administration: 22
Pain medication doses: 5
Biscuits and gravy serving temperature: 110
Biscuits and gravy holding temperature: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Interviewed regarding care conference invitations for R3 |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for family invitations, nail care, pressure ulcer treatment orders, feeding tube care, medication availability, and infection control |
| Certified Nurse Aide 1 | Certified Nurse Aide | Interviewed regarding nail care provision |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Observed providing pressure ulcer treatment and interviewed regarding wound care and medication administration |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Interviewed regarding pain medication administration to R5 |
| Unit Manager 1 | Unit Manager | Interviewed regarding wound vac treatment and feeding tube care |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature complaints and meal service |
Inspection Report
Routine
Deficiencies: 4
Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, medication management, and medication error rates at Sheridan Health and Rehabilitation Center.
Findings
The facility was found deficient in developing and implementing a complete care plan addressing a resident's hearing loss, ensuring psychotropic medications had appropriate end dates, maintaining medication error rates below 5%, and preventing significant medication errors. Specific medication errors and care plan omissions were documented.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to develop a care plan addressing resident R11's hearing loss and interventions related to hearing aid use or refusal. | Level of Harm - Minimal harm or potential for actual harm |
| Psychotropic medication (Ativan) prescribed without an end date for resident R52. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate exceeded 5%, with three errors observed out of 28 medication administration opportunities affecting residents R9 and R24. | Level of Harm - Minimal harm or potential for actual harm |
| Significant medication error where resident R24 was administered immediate release Venlafaxine instead of the ordered extended release formulation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Medication error rate: 10.71
Medication dosage: 0.5
Medication dosage: 37.5
Medication dosage: 150
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Acknowledged missing care plan for R11's hearing loss and medication concerns for R52 and R24 |
| NHA-A | Nursing Home Administrator | Informed of medication errors and deficiencies during exit meeting |
| LPN-C | Licensed Practical Nurse | Observed administering medications to residents R9 and R24 |
| LPN-D | Licensed Practical Nurse | Administered incorrect Venlafaxine formulation to resident R24 and reported medication error |
| ADON-E | Assistant Director of Nursing | Acknowledged concern about lack of care plan for R11's hearing aids |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 3
Jun 22, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely written transfer/discharge notices to residents and their representatives, failure to follow physician orders for weight monitoring, and employment of a qualified Food Service Manager.
Findings
The facility failed to provide written transfer/discharge notices to two residents and their representatives during emergent hospital transfers, failed to follow physician orders for weekly weights for three residents, and employed a Food Service Manager without the required certification and experience.
Complaint Details
The complaint investigation found that two residents (R1 and R14) and their representatives were not provided written transfer/discharge notices during emergent hospital transfers. Additionally, three residents (R2, R30, R32) did not have physician-ordered weekly weights followed. The Food Service Manager lacked required certification and experience.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide timely written notification to residents and their representatives before transfer or discharge, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure physician orders for weekly weights were followed for three residents, risking unrecognized significant weight changes. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to employ a qualified full-time Food Service Manager with required certification and skills for 52 of 53 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 32
Residents affected by transfer notice deficiency: 2
Residents affected by weight monitoring deficiency: 3
Census: 53
Residents affected by Food Service Manager deficiency: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Described emergent transfer process and stated no written notice was given to residents or representatives |
| Director of Nursing | Director of Nursing | Stated unawareness of written notice of transfer and expected weights to be taken as ordered |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated compliance with physician orders for weights and double checking if unclear |
| Food Service Manager | Food Service Manager | Started position in October 2023 and stated in process of obtaining required certification |
| Administrator | Administrator | Provided FSM resume and stated unawareness of FSM lacking required training |
Inspection Report
Routine
Deficiencies: 7
Jul 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including investigation of complaints and review of care practices.
Findings
The facility was found deficient in multiple areas including failure to provide bed hold notices, inadequate treatment and care according to orders, missing neurological checks after falls, missed wound care treatments, inadequate supervision leading to resident elopement and falls, inaccurate weight assessments, inconsistent dialysis communication, and lapses in infection control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Actual harm: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide a bed hold notice upon transfer to the hospital for 1 of 4 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, resident preferences and goals for 4 of 16 residents reviewed, including medication errors, inadequate wound care, and missing neurological checks after falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for 2 of 6 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and assistance devices to prevent accidents for 3 of 6 residents reviewed, resulting in falls and elopement. | Level of Harm - Actual harm |
| Failure to provide enough food/fluids to maintain a resident's health for 1 of 2 residents reviewed, including inaccurate weight assessments and failure to implement dietician recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe, appropriate dialysis care/services for 1 resident due to inconsistent communication between the facility and dialysis center. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including missed hand hygiene during wound treatment for 1 of 5 residents observed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for hospitalization: 4
Residents reviewed for quality of care: 16
Residents reviewed for pressure injuries: 6
Residents reviewed for accidents: 6
Residents reviewed for nutrition: 2
Residents reviewed for dialysis services: 1
Weight loss percentage: 7
Weight loss percentage: 5.3
Number of missed wound treatments: 2
Number of wound dressings observed dated incorrectly: 3
Number of falls missing investigations: 2
Number of falls missing RN assessments and neurological checks: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Observed during wound treatment for R33 with missed hand hygiene opportunity |
| LPN J | Licensed Practical Nurse | Interviewed regarding alcohol order for resident R48 and wound care |
| LPN G | Licensed Practical Nurse | Interviewed regarding alcohol order for resident R48 |
| DON B | Director of Nursing | Interviewed regarding multiple findings including wound care, alcohol orders, fall investigations, and elopement |
| NHA A | Nursing Home Administrator | Interviewed regarding multiple findings including bed hold notice, alcohol orders, fall investigations, and elopement |
| CNA L | Certified Nursing Assistant | Interviewed regarding fall procedures |
| LPN F | Licensed Practical Nurse | Interviewed regarding fall investigations and procedures |
| Wound MD-Q | Wound Specialist | Interviewed regarding wound care and missed treatments for resident R26 |
| Dietician T | Dietician | Interviewed regarding nutrition assessments and weight procedures |
| LPN E | Licensed Practical Nurse | Interviewed regarding dialysis communication procedures |
| CNA N | Certified Nursing Assistant | Interviewed regarding resident elopement |
| LPN I | Licensed Practical Nurse | Interviewed regarding resident elopement |
| KM M | Kitchen Manager | Interviewed regarding resident elopement |
| ADON R | Assistant Director of Nursing | Assisted with wound care for resident R26 |
Inspection Report
Routine
Deficiencies: 10
Jul 12, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, treatment of pressure injuries, accident prevention, and supervision to prevent falls and elopement in a nursing home setting.
Findings
The facility failed to provide appropriate treatment and care for residents with pressure injuries, did not ensure adequate supervision and assistance to prevent falls and elopement, and had deficiencies in fall investigations and wound care treatments. Specific issues included missed wound dressing changes, incorrect pressure mattress settings, inconsistent adherence to alcohol orders, missing neurological checks after falls, and delayed reporting of elopement incidents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Actual harm: 4
Deficiencies (10)
| Description | Severity |
|---|---|
| Staff did not use soap for incontinence care prior to dressing change for resident R33. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R36 was missing neurological checks for unwitnessed falls on 1/10/2023 and 3/10/2023. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R8 did not have RN assessments before being lifted off the ground and neurological checks completed for unwitnessed falls on multiple dates. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R48 received three times the amount of liquor ordered due to staff misunderstanding the physician's order. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R26 had missed wound treatments on 7/8/23 and wound dressings dated incorrectly after treatment schedule change. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R62's pressure relieving air mattress was set incorrectly at 200 mm/hg, not according to resident's weight. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R48 eloped from the facility by climbing out a window and was not immediately reported by staff, delaying interventions. | Level of Harm - Actual harm |
| Residents R36, R8, and R48 did not receive adequate supervision and assistance to prevent continued falls and elopement. | Level of Harm - Actual harm |
| Resident R36 had multiple falls with no complete fall investigation or root cause analysis, and no increased supervision despite intoxicated behaviors. | Level of Harm - Actual harm |
| Resident R8 had missing fall investigations and delayed physician notification for falls. | Level of Harm - Actual harm |
Report Facts
Wound treatments missed: 1
Liquor amount exceeded: 3
Pressure mattress setting: 200
BIMS score: 11
BIMS score: 13
BIMS score: 14
Braden Scale score: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Observed not using soap for incontinence care and discussed wound care for resident R33 |
| DON B | Director of Nursing | Interviewed regarding wound care expectations and fall investigations |
| LPN J | Licensed Practical Nurse | Interviewed about alcohol order for resident R48 |
| LPN G | Licensed Practical Nurse | Interviewed about alcohol order for resident R48 |
| NHA A | Nursing Home Administrator | Interviewed about alcohol order confusion and elopement incident |
| SSC H | Social Service Coordinator | Interviewed about alcohol order for resident R48 |
| CNA L | Certified Nursing Assistant | Interviewed about fall response procedures |
| LPN F | Licensed Practical Nurse | Interviewed about neurological checks and fall investigations |
| CNA N | Certified Nursing Assistant | Interviewed about elopement incident of resident R48 |
| LPN I | Licensed Practical Nurse | Interviewed about elopement incident of resident R48 |
| KM M | Kitchen Manager | Witnessed resident R48 outside facility during elopement |
| LPN P | Licensed Practical Nurse | Observed performing wound care for resident R26 |
| ADON R | Assistant Director of Nursing | Assisted with wound care for resident R26 |
Inspection Report
Deficiencies: 4
Mar 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident safety, nutrition, mental health treatment, and behavioral health training at Sheridan Health and Rehabilitation Center.
Findings
The facility was found deficient in ensuring adequate supervision and safety assessments for residents who leave the building, maintaining appropriate nutritional status for a resident receiving tube feeding, providing appropriate mental health treatment and services to a resident with severe mental health issues, and providing behavioral health training to staff consistent with facility assessment requirements.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and safety assessments to prevent accidents for a resident who eloped and tipped over in their wheelchair. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain acceptable nutritional status and appropriately adjust caloric intake for a resident receiving gastrostomy tube feeding who gained significant weight. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and services to a resident with mental disorder and psychosocial adjustment difficulty, including lack of assessments, care plan revisions, and timely implementation of medication changes. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide behavioral health training consistent with facility assessment to staff caring for residents with mental, psychosocial, or substance use disorders. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight gain: 27.5
Weight gain percentage: 17.5
Weight gain: 23.5
Weight gain percentage: 15
Weight gain: 39
Weight gain percentage: 24.8
Residents with behavioral health needs: 15
Residents with substance use disorders: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Named in relation to safety assessment and staff meeting planning for resident R1. |
| Director of Nursing B | Director of Nursing | Named in relation to safety assessment and mental health treatment discussions for residents R1 and R2. |
| Registered Nurse C | Registered Nurse | Interviewed regarding resident R1's ability to leave the building safely. |
| Licensed Practical Nurse G | Licensed Practical Nurse | Interviewed regarding resident R1's behavior and staff training. |
| Business Office Manager H | Business Office Manager | Interviewed regarding resident R1's behavior. |
| Certified Nursing Assistant I | Certified Nursing Assistant | Interviewed regarding resident R1's behavior and staff training. |
| Social Service Coordinator E | Social Service Coordinator | Interviewed regarding resident R1 and R2's behaviors and staff training. |
| Therapy Director F | Therapy Director | Interviewed regarding safety assessments for residents using wheelchairs. |
| Psychologist J | Psychologist | Provided multiple progress notes regarding resident R2's mental health status and treatment. |
| Director of Maintenance Y | Director of Maintenance | Interviewed regarding calibration and maintenance of facility scales. |
| Registered Nurse Regional Educator L | Registered Nurse Regional Educator | Interviewed regarding mental health treatment and dietitian involvement. |
| Director of Nursing B | Director of Nursing | Interviewed regarding behavioral health training and crisis center procedures. |
| Administrator A | Administrator | Interviewed regarding behavioral health training and facility education processes. |
| Licensed Practical Nurse G | Licensed Practical Nurse | Interviewed regarding behavioral health training after resident R2's return from mental health institute. |
| Certified Nursing Assistant I | Certified Nursing Assistant | Interviewed regarding behavioral health training after resident R2's return from mental health institute. |
Inspection Report
Complaint Investigation
Deficiencies: 14
Feb 22, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident care, including notification of changes in condition, environment cleanliness, abuse investigations, medication errors, laboratory and diagnostic services, and staff competencies.
Findings
The facility had multiple deficiencies including failure to notify representatives of changes in condition, unsafe and unsanitary environment, inadequate abuse investigations and reporting, failure to provide appropriate treatment and care for residents with changes in condition, significant medication errors, failure to ensure licensed nursing staff, and lack of timely laboratory and diagnostic services. Immediate jeopardy was identified related to nursing licensure, quality of care, and medication errors but was removed after corrective actions.
Complaint Details
Complaint investigation revealed multiple deficiencies including failure to notify representatives, unsafe environment, abuse issues, medication errors, and staff competency concerns. Immediate jeopardy was identified related to nursing licensure and quality of care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Immediate jeopardy to resident health or safety: 6
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to notify resident representative of change in condition for 1 of 22 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Unsafe, unclean, and uncomfortable environment affecting 5 of 8 residents on the North unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect residents from abuse and inadequate investigation of resident-to-resident altercations involving R6. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report allegations of abuse for 6 of 7 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to appropriately investigate allegations of abuse for 1 of 7 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care for residents with changes in condition and diabetic care for 4 of 14 sampled residents (R8, R9, R19, and R1). | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers for 2 of 6 residents reviewed (R13 and R7). | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide appropriate care to prevent urinary tract infections for 1 of 4 residents reviewed (R13). | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide timely, quality laboratory services/tests for 2 of 3 residents reviewed (R13 and R6). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nursing staff had appropriate competencies and licensure, including Staff Member-F working as an unlicensed LPN for 90 days and 121 shifts. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide pharmaceutical services to meet the needs of 1 of 3 residents (R6) with medication transcription errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely x-rays/tests and report results to the ordering practitioner for 1 resident (R10). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer the facility in a manner that enables it to use its resources effectively and efficiently, resulting in multiple systemic deficiencies and immediate jeopardy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure nurse aides received dementia management and abuse prevention training for 5 of 5 CNAs reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days Staff Member-F worked without LPN license: 90
Shifts Staff Member-F worked without RN present: 16
Shifts Staff Member-F designated as charge nurse: 6
Residents affected by unsafe environment: 37
Residents affected by abuse issues: 4
Residents affected by failure to report abuse timely: 6
Residents reviewed for medication errors: 3
Residents reviewed for laboratory services: 3
Residents reviewed for pressure injuries: 6
Residents reviewed for catheter care: 4
Residents reviewed for dementia and abuse training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member-F | Unlicensed Practical Nurse (worked as LPN without license) | Worked 90 days and 121 shifts without LPN license, performed nursing duties including medication administration and wound care. |
| Licensed Practical Nurse Unit Manager G | Licensed Practical Nurse Unit Manager | Interviewed regarding nursing assessments and staff competencies. |
| Nursing Home Administrator P | Nursing Home Administrator | Interviewed regarding facility administration and immediate jeopardy. |
| Director of Nursing B | Director of Nursing | Interviewed regarding nursing staff competencies, medication errors, and facility administration. |
| Registered Nurse X | Registered Nurse | Interviewed regarding nursing assessments and staffing. |
| Nurse Practitioner M | Nurse Practitioner | Interviewed regarding resident assessments and medication orders. |
| Clinical Pharmacist FF | Clinical Pharmacist | Interviewed regarding medication regimen reviews. |
| Human Resources Q | Human Resources | Interviewed regarding hiring process and licensure verification. |
| Human Resources R | Human Resources | Interviewed regarding hiring process and licensure verification. |
| Scheduler S | Scheduler | Interviewed regarding scheduling of Staff Member-F. |
| Licensed Practical Nurse EE | Licensed Practical Nurse | Interviewed regarding admission medication orders. |
| Licensed Practical Nurse Unit Manager L | Licensed Practical Nurse Unit Manager | Interviewed regarding medication orders and resident care. |
Inspection Report
Complaint Investigation
Deficiencies: 15
Mar 17, 2022
Visit Reason
The inspection was conducted based on complaints and concerns related to resident rights, use of restraints, care planning, assessments, falls, hygiene, pressure ulcers, respiratory care, pain management, medication reviews, food safety, hospice services, and call light functionality.
Findings
The facility was found deficient in multiple areas including failure to provide feedback on resident grievances, improper use and care planning for physical restraints, incomplete resident assessments, inadequate care planning, failure to provide necessary ADL care, improper pressure ulcer care, inadequate fall investigations, delayed nutritional supplement implementation, unsafe respiratory care, delayed pain medication administration, lack of pharmacist medication review follow-up, failure to coordinate hospice services, food safety violations, and non-functional call light systems.
Complaint Details
Complaint investigation revealed multiple concerns including resident grievances not addressed, improper restraint use, incomplete assessments, inadequate care planning, falls, hygiene issues, pressure ulcer care, respiratory care, pain management, medication review, hospice coordination, food safety, and call light functionality.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 14
Level of Harm - Actual harm: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to provide feedback to residents regarding grievances voiced at Resident Council meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Use of abdominal binder as a physical restraint without proper assessment or care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Incomplete Care Area Assessments (CAAs) for multiple residents, lacking summaries of triggered areas. | Level of Harm - Minimal harm or potential for actual harm |
| Inaccurate assessment documentation for resident R31 regarding pressure injuries. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop comprehensive care plans addressing all resident needs including ADLs, restraints, and hospice care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary ADL care including showers and tracheostomy site care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and timely assessments. | Level of Harm - Actual harm |
| Inadequate fall investigations and failure to update care plans after falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain beds in lowest position as per care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to monitor dialysis catheter site daily for resident requiring dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe food handling practices; food service employee contaminated ready to eat food by touching with gloved hands after touching non-sanitized surfaces. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to coordinate hospice services including lack of hospice plan of care, medication orders, and communication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide respiratory care consistent with physician orders including uncovered tracheostomy stoma and lack of oxygen tubing change orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely and adequate pain management for resident receiving hospice care. | Level of Harm - Actual harm |
| Failure to ensure working call light systems in resident rooms, including taped down or missing call light buttons with exposed wires. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 15
Weight loss: 22.4
Weight loss percentage: 14.7
Falls: 3
Medication dose: 40
Medication dose: 5
Medication dose: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed regarding restraint use, pressure ulcer care, fall investigations, nutritional supplement delay, respiratory care, pain management, dialysis site monitoring, and medication review |
| NHA-A | Nursing Home Administrator | Interviewed regarding care planning, fall investigations, nutritional supplement delay, respiratory care, pain management, and call light system issues |
| ADON-D | Assistant Director of Nursing | Interviewed regarding pressure ulcer care, fall investigations, call light system issues, and dialysis site monitoring |
| ADON-C | Assistant Director of Nursing | Interviewed regarding call light system issues and respiratory care |
| RN-J | Hospice Nurse | Interviewed regarding pain medication changes and communication with facility |
| RN-O | Corporate Registered Nurse | Interviewed regarding oxygen tubing change orders and hospice communication |
| SS-G | Social Services | Interviewed regarding PASARR screening and hospice provider change |
| LPN-T | Licensed Practical Nurse | Interviewed regarding fall investigations |
| LPN-S | Licensed Practical Nurse | Interviewed regarding fall investigations and call light system |
| CNA-M | Certified Nursing Assistant | Interviewed regarding resident pain complaints |
| CNA-L | Certified Nursing Assistant | Interviewed regarding resident pain complaints |
| Dietician-H | Dietician | Interviewed regarding nutritional supplement delay |
| Dietary Manager-E | Dietary Manager | Interviewed regarding food safety and hand hygiene |
| Cook-F | Cook | Observed contaminating ready to eat food with gloved hands |
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