Deficiencies (last 3 years)
Deficiencies (over 3 years)
30.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
567% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 29, 2025
Visit Reason
The inspection was conducted due to a complaint regarding a staff member burning sage inside the facility, raising concerns about safety and potential impairment.
Findings
The facility failed to ensure the resident environment was free from accident hazards as a staff member burned sage in the building without verification that it was extinguished and without providing staff education on safety. The incident involved suspicion of impairment, but a drug test was negative and no drug paraphernalia was found.
Complaint Details
The complaint involved a staff member (RN C) burning sage in the facility, causing a strong smell and suspicion of marijuana use. RN C was suspected of impairment but denied smoking marijuana and tested negative on a drug test. The facility did not verify that the sage was extinguished and did not provide education to staff following the incident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Date of incident: Jul 17, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Involved in burning sage incident and subject of investigation |
| RN D | Registered Nurse | Reported the incident and suspected impairment |
| RN E | Registered Nurse | Interviewed regarding smoky smell and incident |
| NHA A | Nursing Home Administrator | Managed incident response and interviewed by surveyor |
| DON B | Director of Nursing | Informed about incident and involved in follow-up |
Inspection Report
Inspection Report
Deficiencies: 12
May 5, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, medication administration, grievance handling, restraint use, care planning, discharge planning, fall prevention, pain management, medication storage, and food safety standards.
Findings
The facility was found deficient in multiple areas including failure to protect resident rights related to uninvited wandering by a resident, inadequate clinical appropriateness for medication self-administration, incomplete grievance investigations, improper use of physical restraints, incomplete and non-person-centered care plans, inadequate discharge planning, failure to honor resident preferences especially religious needs, insufficient assistance with activities of daily living, inadequate pressure ulcer care, insufficient fall prevention and supervision, inadequate pain management, expired medications on medication carts, and improper food temperature monitoring.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Level of Harm - Actual harm: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility did not ensure residents were treated with respect and dignity; resident R82 wandered into other residents' rooms uninvited causing distress. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R17 was observed self-administering medications without a completed assessment or order indicating clinical appropriateness. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to document thorough investigation and resolution of grievance related to staff use of personal cell phones during work hours. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R27 was restrained by locked brakes on her Broda chair, preventing self-propulsion and movement. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to develop and implement comprehensive care plans that meet residents' personal preferences and needs, including religious preferences for residents R53 and R70, and failed to use interpreter services for R28. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R76's discharge care plan did not reflect his goal to move to assisted living. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide toileting assistance to dependent residents R37 and R293, resulting in dignity concerns and inadequate personal care. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R40 with a stage 4 pressure injury was not repositioned per physician orders and care plan was not updated accordingly. | Level of Harm - Minimal harm or potential for actual harm |
| Resident R27 had multiple falls with no evidence of increased supervision or comprehensive review of fall data by the interdisciplinary team. | Level of Harm - Actual harm |
| Resident R31 with chronic pain experienced exacerbated pain due to use of EZ stand lift; facility failed to reassess pain or implement alternative transfer methods. | Level of Harm - Minimal harm or potential for actual harm |
| Medication carts contained expired medications and medications without proper labeling including open dates. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety; food temperatures were not properly taken or recorded. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Falls: 23
Pain medication administrations: 16
Pain medication administrations: 15
Pain medication administrations: 6
Pain medication administrations: 13
Residents: 94
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Interviewed regarding expired medications and medication cart checks |
| DON B | Director of Nursing | Interviewed regarding multiple deficiencies including wandering resident, medication self-administration, grievance follow-up, restraint use, care planning, discharge planning, toileting assistance, pressure ulcer care, fall prevention, pain management, and medication storage |
| SW K | Social Worker | Interviewed regarding discharge planning and resident R31's pain and transfer concerns |
| RN C | Registered Nurse | Interviewed regarding resident R31's pain and transfer status, and toileting assistance for resident R37 |
| CNA F | Certified Nursing Assistant | Interviewed regarding resident R31's pain during transfers and religious preferences of resident R53 |
| CNA D | Certified Nursing Assistant | Interviewed regarding toileting assistance for resident R37 and religious preferences of resident R53 |
| RN DD | Registered Nurse | Interviewed regarding restraint use for resident R27 |
| NHA A | Nursing Home Administrator | Interviewed regarding wandering resident R82 |
| LPN GG | Licensed Practical Nurse, Unit Manager | Interviewed regarding medication self-administration assessment for resident R17 |
| CNA R | Certified Nursing Assistant | Interviewed regarding toileting assistance for resident R37 and shaving frequency for resident R293 |
| RN H | Registered Nurse | Interviewed regarding wandering resident R82 and toileting assistance for resident R37 |
| CNA Y | Certified Nursing Assistant | Interviewed regarding wandering resident R82 |
| LPN X | Licensed Practical Nurse | Interviewed regarding wandering resident R82 |
| SW CC | Social Worker | Interviewed regarding wandering resident R82 and related grievances |
| CNA V | Certified Nursing Assistant | Interviewed regarding communication with resident R28 |
| LPN GG | Licensed Practical Nurse | Interviewed regarding medication self-administration assessment for resident R17 |
| CNA I | Certified Nursing Assistant | Interviewed regarding religious preferences of resident R70 and pain during transfers for resident R31 |
| DM P | Dietary Manager | Interviewed regarding food temperature monitoring |
| DA Q | Dietary Aide | Observed taking food temperatures during lunch meal |
| AD J | Activities Director | Interviewed regarding religious preferences and grievances |
Inspection Report
Deficiencies: 3
Mar 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations related to accident hazards, diet texture adherence, medical record accuracy, and resident safety following complaints and routine oversight.
Findings
The facility failed to prevent falls for resident R9 related to unsafe use of a lift chair, failed to follow prescribed diet texture for resident R6 with undocumented exceptions, and had conflicting information in medical records regarding resident R5's ability to self-administer medication. The facility also lacked evidence of staff education on fall prevention and proper documentation of dietary exceptions.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the facility was free of accident hazards and provide adequate supervision to prevent falls for resident R9, resulting in actual harm including a femur fracture. | Level of Harm - Actual harm |
| Failed to follow prescribed easy to chew diet for resident R6, providing snacks not consistent with diet orders and lacking documented risk and benefit analysis for exceptions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate medical records for resident R5, with conflicting care plan information regarding self-administration of medication. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accident hazards: 14
Residents reviewed for diet texture: 14
Residents reviewed for medical records: 14
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 2 | LPN | Familiar with resident R5 and medication administration; aware of self-medication orders |
| Director of Nursing | DON | Acknowledged conflicting care plan information for resident R5 and undocumented diet exceptions for resident R6 |
| Speech Therapist and Language Pathologist | ST | Allowed dietary exceptions for resident R6 without documenting in care plan |
| Registered Dietician | RD | Unaware of undocumented dietary exceptions for resident R6 |
| Certified Nursing Assistant 2 | CNA | Reported resident R6's diet and snack preferences |
| Certified Nursing Assistant 3 | CNA | Reported providing non-compliant snacks to resident R6 |
| Administrator | Reported lack of fall prevention education and missing documentation regarding recliner use for resident R9 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 11, 2024
Visit Reason
The inspection was conducted following a complaint related to a resident fall and concerns about staff not following the resident's care plan, as well as issues with bed rail installation and safety.
Findings
The facility failed to ensure adequate supervision and accident hazard prevention for a resident who fell out of bed due to staff not following the care plan and inadequate staff education. Additionally, the facility failed to properly install, test, and maintain bed rails for multiple residents, lacking documentation of required safety testing prior to November 2024.
Complaint Details
The complaint investigation was substantiated, identifying that staff failed to follow the care plan for resident R1, resulting in a fall. The facility was aware of the issue but did not ensure all staff were educated. Additionally, bed rails for residents R3, R6, R7, and R8 were installed without proper safety testing documentation prior to November 2024.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure resident environment is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident fall due to staff not following care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide education and competency exams for all staff related to following resident care plans, resulting in staff performing cares alone contrary to care plan requirements. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure correct installation, use, and maintenance of bed rails for 4 of 5 residents reviewed, including lack of Bed System Measurement Device Test prior to installation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accidents: 3
Residents affected by bed rail deficiency: 4
Staff not educated per post-event action plan: 8
Date of incident: Oct 27, 2024
Date survey completed: Nov 11, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in findings for performing cares alone contrary to care plan and not being educated per facility plan |
| NHA A | Nursing Home Administrator | Interviewed regarding fall incident and staff education deficiencies |
| MS C | Maintenance Supervisor | Interviewed regarding bed rail installation and testing procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 21, 2024
Visit Reason
The inspection was conducted following a complaint and incident involving a resident (R5) who sustained burns from spilled hot coffee while in bed, to assess the facility's compliance with safety and supervision requirements related to hot liquids.
Findings
The facility failed to ensure adequate supervision and safety measures for residents handling hot liquids, resulting in a resident sustaining superficial partial thickness burns covering approximately 7% of total body surface area. The facility lacked processes for monitoring hot liquid temperatures and safety assessments prior to the incident. Post-incident, the facility implemented temperature monitoring, staff education, and resident hot liquid risk assessments.
Complaint Details
The complaint investigation was triggered by an incident on 10/13/2024 where resident R5 spilled hot coffee in bed, resulting in second-degree burns requiring emergency treatment. The investigation included interviews, record reviews, and observations related to the incident and facility practices.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and safety measures to prevent accidents related to hot liquids, resulting in actual harm to a resident. | Level of Harm - Actual harm |
| Failure to monitor and document behaviors and side effects related to psychotropic medication for a resident, including inappropriate use of antipsychotic medication without proper diagnosis. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Total Body Surface Area (TBSA) burned: 7
Burn wound dimensions: 24
Burn wound dimensions: 30
Burn wound dimensions: 0.1
Burn wound dimensions: 10
Burn wound dimensions: 8
Coffee temperature: 185
Coffee temperature: 138.7
Coffee temperature: 135
Coffee temperature: 132
Psychotropic medication behavior observations: 93
Psychotropic medication behavior observations: 90
Psychotropic medication behavior observations: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R5 | Resident | Resident who sustained burns from spilled hot coffee. |
| DON B | Director of Nursing | Provided information about the incident, facility policies, and corrective actions. |
| RN G | Registered Nurse | Responded to incident, assessed resident, and coordinated emergency care. |
| CNA D | Certified Nursing Assistant | Delivered coffee to resident and assisted after incident. |
| PT E | Physical Therapist | Provided therapy assessment and information about resident mobility. |
| VPC F | Vice President of Culinary | Provided information about coffee temperature monitoring and kitchen procedures. |
| NHA A | Nursing Home Administrator | Provided information about facility corrective actions and policies. |
| R1 | Resident | Resident receiving psychotropic medications with behavior monitoring deficiencies. |
| RN I | Registered Nurse | Interviewed regarding R1's behaviors. |
| CNA J | Certified Nursing Assistant | Interviewed regarding R1's behaviors. |
| LPN K | Licensed Practical Nurse | Interviewed regarding R1's behaviors. |
| CNA L | Certified Nursing Assistant | Interviewed regarding R1's behaviors. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and proper diet adherence for a resident (R2) with altered diets, which led to choking and aspiration events.
Findings
The facility failed to supervise resident R2 properly and ensure he received food consistent with his prescribed diet, resulting in two choking episodes and hospitalizations. Immediate Jeopardy was identified but removed after corrective actions. The facility also failed to conduct annual performance evaluations for some CNAs.
Complaint Details
The complaint investigation focused on resident R2 who had two choking episodes within a month, including one on 7/27/24 involving a hot dog and another on 8/13/24 involving honeydew melon not consistent with his prescribed Level 6 soft and bite-sized diet. The facility failed to supervise and ensure correct diet adherence, resulting in aspiration events and hospitalizations. Immediate Jeopardy was identified on 9/5/24 and removed on 9/6/24 after corrective actions.
Severity Breakdown
Immediate jeopardy: 1
Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision and proper diet adherence for resident R2, leading to choking and aspiration events. | Immediate jeopardy |
| Failure to conduct annual performance evaluations for 3 of 5 randomly sampled CNAs. | Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 1
CNA performance evaluations missing: 3
Potato size: 4.5
Potato size: 4
Blood Pressure: 212
Blood Pressure: 99
Oxygen saturation: 85
Oxygen administered: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA G | Certified Nursing Assistant | Named in providing incorrect diet (honeydew melon) to resident R2 |
| RN D | Registered Nurse | Responded to choking incident and provided statements about diet and supervision |
| LPN E | Licensed Practical Nurse | Present during choking incident and provided statements about meal ticket responsibilities |
| CK F | Cook | Served food according to meal tickets and acknowledged no training on diets |
| DON B | Director of Nursing | Interviewed regarding expectations and corrective actions after incidents |
| NHA A | Nursing Home Administrator | Interviewed regarding responsibilities and education related to meal service |
Inspection Report
Complaint Investigation
Deficiencies: 8
Jun 27, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding medication errors, grievance resolution, abuse reporting, neglect investigations, pressure injury care, diabetic foot care, supervision to prevent accidents, and pharmaceutical services at the facility.
Findings
The facility failed to immediately notify physicians of medication errors, did not ensure prompt resolution of grievances, failed to report alleged abuse to the state agency, did not thoroughly investigate abuse and neglect allegations, did not implement proper pressure injury prevention and diabetic foot care, failed to maintain adequate supervision for a resident on 1:1 safety monitoring, and did not ensure availability of prescribed medications.
Complaint Details
The visit was complaint-related involving medication errors, grievance handling, abuse allegations, neglect investigations, pressure injury care, diabetic foot care, supervision failures, and pharmaceutical service deficiencies. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to immediately notify the resident's physician when a medication was not administered as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure prompt resolution of grievances for a resident who reported staff frustration and neglect. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse to the administrator and state agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate allegations of abuse and neglect for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement professional standards of practice to prevent pressure injury development and promote healing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide diabetic foot care daily in accordance with professional standards. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and safety to prevent accidents for a resident on 1:1 supervision. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services ensuring accurate acquisition, receipt, dispensing, and administration of medications, resulting in a resident not receiving ordered Vitamin B Complex-C medication. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication doses not administered: 16
Pressure wound size: 1.5
Antibiotic administrations: 15
Dates of medication unavailability: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Reported medication error regarding R5's Vitamin B Complex-C and completed medication error paperwork. |
| ADON G | Assistant Director of Nursing | Notified about medication error for R5, contacted pharmacy, but failed to notify physician timely. |
| DON B | Director of Nursing | Involved in medication order approval, expected physician notification for medication unavailability, and acknowledged failure to follow up on grievance and supervision issues. |
| RN C | Registered Nurse | Charge nurse who followed up on grievance regarding R8's meal setup and reported to DON B. |
| CNA D | Certified Nursing Assistant | Assisted R8 with meal setup after CNA E left her unattended. |
| CNA E | Certified Nursing Assistant | Left R8 unattended during meal setup and was called a derogatory name by R8. |
| NHA A | Nursing Home Administrator | Handled grievances and abuse allegations but failed to report abuse and conduct thorough investigations. |
| RN J | Registered Nurse | Indicated interventions should be put in place immediately for residents at risk for pressure injury. |
| RN K | Registered Nurse | Indicated interventions should have been initiated for R3's reddened bunion. |
| RN M | Registered Nurse | Applied dressing to R3's foot but did not put intervention in place immediately. |
| RN I | Registered Nurse | Observed fall of R6 and noted CNA H left resident unattended despite 1:1 supervision requirement. |
| CNA H | Certified Nursing Assistant | Assigned 1:1 supervision for R6 but left resident unattended leading to fall. |
| RN L | Registered Nurse | Indicated diabetic foot checks are completed if ordered and documented on TAR. |
Inspection Report
Complaint Investigation
Deficiencies: 13
May 2, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, neglect, or theft, failure to respond appropriately to alleged violations, incomplete assessments, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screenings, inadequate activities programming, improper wound care, inaccurate nurse staffing postings, medication errors, improper medication storage and labeling, incomplete infection prevention and control program, and deficiencies in antibiotic stewardship and vaccination policies.
Findings
The facility failed to timely report and investigate abuse allegations, did not complete required assessments and screenings, provided inadequate activities programming, failed to document wound care properly, had inaccurate nurse staffing postings, medication errors, improper medication storage and labeling, incomplete infection control surveillance and outbreak management, and did not fully implement antibiotic stewardship and vaccination policies.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to report and investigate abuse allegations, incomplete assessments, inadequate activities, medication errors, infection control issues, and deficiencies in antibiotic stewardship and vaccination policies.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to all alleged violations, including failure to investigate potential misappropriation of narcotic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete comprehensive assessments as required, including discharge MDS assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure MDS assessments accurately reflect resident status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete PASARR Level II screening for residents residing longer than 30 days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide an ongoing program of activities designed to meet residents' interests and physical, mental, and psychosocial well-being. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, resident preferences, and goals, including lack of weekly wound measurements. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post accurate nurse staffing information daily in an accessible area. | Level of Harm - Potential for minimal harm |
| Failure to ensure residents are free from significant medication errors, including missed doses of antipsychotic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals are labeled and stored in accordance with professional principles, including undated and unlabeled medications and improper storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including incomplete surveillance, inaccurate infection rates, incomplete outbreak summaries, and improper infection control practices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement a program that monitors antibiotic use, including inappropriate antibiotic use without proper indication or monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, including lack of documentation of education, consent, administration, or declination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 27
Residents affected by activities deficiency: 7
Residents affected by infection control deficiency: 106
Residents affected by medication error: 1
Residents affected by antibiotic stewardship deficiency: 4
Residents affected by vaccination documentation deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding abuse investigations, wound care, antibiotic stewardship, medication errors, and infection control |
| NHA A | Nursing Home Administrator | Interviewed regarding abuse investigations, activities programming, antibiotic stewardship, and infection control |
| LPN/IP D | Licensed Practical Nurse/Infection Preventionist | Interviewed regarding abuse investigations, infection control, antibiotic stewardship, and medication storage |
| RN K | Registered Nurse | Interviewed regarding abuse investigations and medication errors |
| Scheduler O | Interviewed regarding nurse staffing postings | |
| AA L | Activity Aide | Interviewed regarding activities programming |
| AD M | Activity Director | Interviewed regarding activities programming |
| RN E | Registered Nurse | Interviewed regarding antibiotic stewardship and wound care |
| RN P | Registered Nurse | Interviewed regarding medication storage |
| RN Q | Registered Nurse | Interviewed regarding medication storage |
| RN R | Registered Nurse | Interviewed regarding medication storage |
| LPN F | Licensed Practical Nurse | Interviewed regarding infection control practices |
| CNA G | Certified Nursing Assistant | Observed and interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 13
May 2, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, neglect, or theft, failure to respond appropriately to alleged violations, incomplete assessments, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screenings, inadequate activities programming, improper wound care, inaccurate nurse staffing postings, medication errors, improper medication storage and labeling, infection prevention and control program deficiencies, antibiotic stewardship issues, and incomplete pneumococcal vaccination documentation.
Findings
The facility failed to timely report and investigate abuse allegations, did not complete required assessments and screenings, provided inadequate activities programming, failed to ensure proper wound care documentation, had inaccurate nurse staffing postings, medication errors including missed doses, improper medication storage and labeling, incomplete infection control surveillance and outbreak management, deficient antibiotic stewardship, and lacked complete documentation for pneumococcal vaccinations.
Complaint Details
The complaint investigation revealed multiple issues including failure to report and investigate abuse allegations, incomplete assessments and screenings, inadequate activities, wound care deficiencies, inaccurate staffing postings, medication errors, improper medication storage, infection control program deficiencies, antibiotic stewardship failures, and incomplete vaccination documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Potential for minimal harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to all alleged violations including failure to investigate potential misappropriation of narcotic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete comprehensive assessments including discharge Minimum Data Set (MDS) assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate Minimum Data Set (MDS) assessments reflecting resident status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete required PASARR Level II screenings for residents residing longer than 30 days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide an ongoing program of activities meeting residents' interests and needs, including lack of weekend and evening activities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate wound treatment and care according to orders and professional standards, including lack of weekly wound measurements. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to post accurate nurse staffing information daily in an accessible area. | Level of Harm - Potential for minimal harm |
| Failure to ensure residents are free from significant medication errors, including missed doses of antipsychotic medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals are labeled and stored according to professional principles, including undated and unlabeled medications, improper refrigeration, and expired medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an effective infection prevention and control program, including incomplete infection surveillance, inaccurate outbreak summaries, and improper infection control practices. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement a program that monitors antibiotic use, including inappropriate antibiotic prescribing and lack of documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for flu and pneumococcal vaccinations, including lack of documentation of consent, declination, or administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 27
Residents affected by abuse reporting deficiency: 2
Residents affected by PASARR screening deficiency: 4
Residents affected by activities deficiency: 7
Residents affected by wound care deficiency: 1
Residents affected by medication error: 1
Residents affected by antibiotic stewardship deficiency: 5
Residents affected by pneumococcal vaccination documentation deficiency: 3
Facility census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding abuse investigations, wound care, antibiotic stewardship, and medication errors |
| NHA A | Nursing Home Administrator | Interviewed regarding abuse investigations, activities programming, antibiotic stewardship, and vaccination documentation |
| LPN/IP D | Licensed Practical Nurse/Infection Preventionist | Interviewed regarding abuse reporting, infection control, antibiotic stewardship, and vaccination documentation |
| RN K | Registered Nurse | Interviewed regarding missing narcotic patch and medication error |
| MDSC H | MDS Coordinator | Interviewed regarding MDS accuracy |
| AD M | Activity Director | Interviewed regarding activities programming |
| AA L | Activity Aide | Interviewed regarding activities programming |
| RN E | Registered Nurse | Interviewed regarding wound care and antibiotic stewardship |
| RN P | Registered Nurse | Interviewed regarding medication storage and labeling |
| RN R | Registered Nurse | Interviewed regarding medication storage and labeling |
| RN T | Registered Nurse | Interviewed regarding medication storage and labeling |
| Scheduler O | Interviewed regarding nurse staffing posting | |
| CNA G | Certified Nursing Assistant | Observed and interviewed regarding infection control breach |
| LPN F | Licensed Practical Nurse | Interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 6
Apr 10, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide a support person for resident R1 to attend medically necessary physician appointments, unresolved resident grievances, inadequate care planning, insufficient assistance with activities of daily living for some residents, and medication administration errors.
Findings
The facility failed to ensure resident R1 was treated with dignity and respect by not providing support for medical appointments, did not promptly resolve grievances, failed to revise care plans to address resident needs, did not provide adequate assistance with incontinence care for several residents, and had multiple medication administration errors including missed doses and a medication dosage error.
Complaint Details
The complaint investigation focused on resident R1's lack of support for attending medical appointments, grievances not being documented or investigated, and medication administration errors affecting multiple residents. The facility was found to have failed in these areas, with ongoing communication documented between the facility and R1's family member and physician. The facility acknowledged the need for a support person by 5/1/2024 and risk of APS involvement if not addressed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide a support person for resident R1 to attend medically necessary physician appointments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to make prompt efforts to resolve resident grievances for resident R1. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to revise resident R1's care plan to include the need for a support person during appointments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary assistance with incontinent cares for 3 residents (R16, R23, R24), including use of double briefs without care plan documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services to meet the needs of residents, including missed medications for 6 residents (R4, R5, R7, R13, R18, R21). | Level of Harm - Minimal harm or potential for actual harm |
| Medication error with resident R21 receiving the wrong dose of Venlafaxine (150 mg instead of 300 mg). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for grievances: 7
Residents reviewed for ADLs: 6
Residents reviewed for medications: 15
Medication error rate: 8.3
Missed medication doses: 6
Residents affected by ADL care deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Discussed support person policy and resident safety concerns related to R1's medical appointments |
| DON B | Director of Nursing | Discussed grievance process, medication administration policies, and medication error involving R21 |
| VPCS F | Vice President of Clinical Services | Provided information on pharmacy transition and medication availability issues |
| MA L | Medication Aide | Administered incorrect dose of Venlafaxine to resident R21 |
| RN M | Registered Nurse | Interviewed regarding grievance allegations |
| CNA G | Certified Nursing Assistant | Observed providing double incontinence products to resident R23 |
| CNA H | Certified Nursing Assistant | Interviewed about double briefing practices |
| CNA I | Certified Nursing Assistant | Interviewed about double briefing practices |
| CNA J | Certified Nursing Assistant | Interviewed about double briefing practices |
| CNA K | Certified Nursing Assistant | Interviewed about double briefing practices |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 8, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident safety, specifically related to fall prevention, supervision, and call light response times at Complete Care at Maple Grove LLC.
Findings
The facility failed to ensure adequate supervision and fall interventions for residents requiring increased supervision, resulting in a resident (R5) sustaining multiple fractures after a fall. The facility also lacked policies and processes for monitoring alarm function and implementation. Additionally, a resident (R7) experienced excessive call light wait times, and another resident (R6) lacked a working call light pendant, impairing their ability to summon assistance.
Complaint Details
The investigation was complaint-driven, focusing on incidents involving residents R5, R6, and R7. R5 sustained injuries from a fall due to inadequate supervision and alarm management. R7 reported excessive call light wait times and concerns about staff assistance. R6 lacked a functional call light pendant, impairing communication with staff.
Severity Breakdown
Level of Harm - Actual harm: 3
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision or fall interventions for residents requiring increased supervision, leading to a fall with injury. | Level of Harm - Actual harm |
| Failure to have a policy or process to monitor alarm implementation dates, expiration dates, and function to ensure safety. | Level of Harm - Actual harm |
| Failure to ensure call lights are answered timely, resulting in excessive wait times for assistance. | Level of Harm - Actual harm |
| Failure to ensure all residents have a working call system available in their rooms and bathrooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Fall incident time: 1611
Call light response time: 4095
Fall history: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA N | Certified Nursing Assistant | Named in fall incident involving R5; turned off alarm and left resident unattended |
| Pharm Tech J | Pharmacy Technician | Discovered R5 on the floor after fall and notified nursing staff |
| RN Charge Nurse M | Registered Nurse/Charge Nurse | Documented progress notes and provided staff education after fall incident |
| RN K | Registered Nurse | Witnessed fall incident and assisted with resident assessment |
| CNA O | Certified Nursing Assistant | Observed leaving R5 unattended in bathroom despite care plan |
| NHA A | Nursing Home Administrator | Interviewed regarding fall incident and facility policies |
| RN D | Registered Nurse | Interviewed regarding R6's call light pendant status |
| Facility Maintenance E | Maintenance Staff | Responsible for fixing call lights and replacing parts |
| Regional Nurse Consultant C | Regional Nurse Consultant | Provided expert opinion on call light response and alarm monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 4, 2023
Visit Reason
The inspection was conducted due to complaints and self-reports regarding alleged neglect and abuse of residents, including failure to timely report suspected abuse and failure to thoroughly investigate alleged violations.
Findings
The facility failed to timely report an allegation of abuse for one resident (R3), did not thoroughly investigate alleged violations for four residents (R2, R3, R5, R7), and failed to ensure proper safety interventions for one resident (R1) resulting in a fall and death. Staff education and follow-up were inadequate, and immediate jeopardy was identified related to resident safety.
Complaint Details
The complaint investigation was triggered by allegations of neglect and abuse involving multiple residents. The facility self-reported incidents including a resident (R3) sitting in feces for over three hours, failure to investigate allegations thoroughly for residents R2, R3, R5, and R7, and a fall incident involving resident R1 that resulted in death. The investigation found delays in reporting, inadequate follow-up, and failure to implement safety protocols.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse for resident R3. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate alleged violations for residents R2, R3, R5, and R7. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper safety interventions for resident R1, resulting in a fall with injury and death. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents sampled: 8
Residents reviewed for investigation: 7
Residents affected by investigation findings: 4
Residents affected by fall incident: 1
Fall mat height: 10
Fall mat height: 12
Bed height at incident: 24
Call light wait time: 48
Time resident sat in feces: 180
CNA H shifts worked without education: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Management staff who followed up on incident with R3 and provided education |
| NHA A | Nursing Home Administrator | Administrator involved in investigation and follow-up of incidents |
| CNA H | Certified Nursing Assistant | Staff involved in fall incident with resident R1 |
| CNA C | Certified Nursing Assistant | Staff interviewed regarding incident with resident R2 |
| RN D | Registered Nurse | Staff interviewed regarding incident with resident R2 |
| CNA J | Certified Nursing Assistant | Staff involved in neglect incident with resident R3 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Oct 9, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to report and investigate suspected abuse and neglect, specifically related to a missing Fentanyl pain patch and an injury of unknown origin on residents.
Findings
The facility failed to timely report and investigate a missing Fentanyl patch for one resident, and failed to report an injury of unknown origin for another resident. Additionally, the facility failed to ensure accurate implementation of physician orders for medications for multiple residents, resulting in medication errors.
Complaint Details
The complaint investigation revealed failures in reporting and investigating suspected abuse and neglect involving a missing Fentanyl patch for resident R11 and an unreported suspicious injury for resident R28. The facility did not report these incidents to the State Survey Agency as required.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to a missing Fentanyl patch. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report an injury of unknown source that was suspicious due to its location and extent. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to investigate a resident's missing pain patch as outlined in abuse policies related to misappropriation of resident property. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to respond appropriately to all alleged violations related to the missing Fentanyl patch. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physicians' orders were accurately implemented for 5 out of 8 residents reviewed for medication errors. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents prescribed Fentanyl patches: 4
Residents reviewed for abuse: 3
Residents affected: 1
Residents affected: 1
Residents reviewed for medication errors: 8
Residents with medication errors: 5
Days ferrous sulfate given daily instead of every other day: 59
Missed doses of antibiotic: 8
Missed doses of Coumadin: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Notified nursing manager of missing Fentanyl patch and involved in patch checks |
| DON B | Director of Nursing | Involved in investigation of bruising on resident R28 and reporting process |
| RN D | Registered Nurse | Reported bruising on resident R28 to ADON |
| LPN C | Licensed Practical Nurse | Noticed bruising on resident R28 and reported to charge nurse |
| CNA E | Certified Nursing Assistant | Provided care to resident R28 and reported no prior bruising |
| RN2 | Registered Nurse | Confirmed facility's documentation process for residents with Fentanyl patches |
| Health Information Services (HIS) staff | Oversight over input of physicians' orders and order verification process | |
| Administrator | Provided information on missing Fentanyl patch and investigation status |
Inspection Report
Routine
Census: 110
Deficiencies: 7
Feb 27, 2023
Visit Reason
Routine inspection of Complete Care at Maple Grove LLC nursing home to assess compliance with regulatory requirements including resident care, staffing, and safety.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, inadequate assistance with activities of daily living such as showers and incontinence care, insufficient staffing levels impacting resident care and call light response times, improper pressure ulcer care leading to worsening wounds, inappropriate catheter care increasing UTI risk, medication administration errors, and untrained feeding assistants providing resident dining assistance.
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 make prompt efforts to resolve resident grievances, specifically regarding a lost hearing aid. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide care and assistance for activities of daily living including missed showers and inadequate incontinence care for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide sufficient nursing staff to meet resident needs, resulting in missed care and long call light response times. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement professional standards of practice to prevent pressure injuries from worsening, including lack of weekly wound assessments and treatment changes. | Level of Harm - Actual harm |
| Failure to provide appropriate catheter care and prevent urinary tract infections, including uncovered catheter bag on floor and improper hand hygiene during catheter care. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate of 5% or greater, including improper administration of nasal spray and crushing enteric coated tablets. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure feeding assistants completed state-approved training, with untrained staff and family members assisting residents with dining. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 8
Residents affected: 6
Residents affected: 1
Residents affected: 2
Medication errors: 2
Residents affected: 4
Facility census: 110
Staffing ratios: 1.23
Staffing ratios: 1.18
Staffing ratios: 1.8
Call light response time: 55
Call light response time: 128
Call light response time: 32
Call light response time: 37
Call light response time: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SW G | Social Worker | Interviewed regarding lost hearing aid grievance and failure to file grievance |
| NHA A | Nursing Home Administrator | Interviewed regarding grievance process and staffing issues |
| CNA I | Certified Nursing Assistant | Interviewed regarding incontinence care and staffing |
| CNA P | Certified Nursing Assistant | Interviewed regarding staffing shortages and missed showers |
| CNA S | Certified Nursing Assistant | Interviewed regarding staffing shortages, missed showers, call light response, and resident complaints |
| RN H | Registered Nurse | Interviewed regarding staffing shortages and missed showers |
| DON B | Director of Nursing | Interviewed regarding staffing, wound care, catheter care, medication administration, and feeding assistant training |
| RN J | Registered Nurse | Assessed and documented wound care for resident R104 |
| CNA L | Certified Nursing Assistant | Observed performing catheter care without proper hand hygiene |
| MT T | Medication Technician | Observed administering nasal spray incorrectly and crushing enteric coated tablet |
| HSK U | Housekeeping Staff | Assisted residents with dining without training |
| RN R | Registered Nurse | Aware of untrained housekeeping staff assisting with dining |
| FM V | Family Member | Reported staffing shortages and assisted with feeding residents |
Inspection Report
Routine
Census: 104
Deficiencies: 10
Feb 27, 2023
Visit Reason
Routine inspection of Complete Care at Maple Grove LLC nursing home to assess compliance with regulatory requirements including resident rights, restraint use, activities of daily living, pressure ulcer care, catheter care, medication administration, staffing, feeding assistance, food safety, and garbage disposal.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, improper use of physical restraints, inadequate assistance with activities of daily living such as showers and incontinence care, failure to properly assess and treat pressure ulcers, inappropriate catheter care, medication administration errors, insufficient nursing staff to meet resident needs, untrained feeding assistants, improper food thawing and storage, and improper garbage disposal.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Actual harm: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to make prompt efforts to resolve resident grievances, specifically regarding a lost hearing aid for resident R265. | Level of Harm - Minimal harm or potential for actual harm |
| Use of a full body-length pillow as a physical restraint without assessment, physician order, or care plan for resident R97. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate assistance with activities of daily living including showers and incontinence care for multiple residents (R25, R30, R104, R32, R42, R54, R88, R60). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement professional standards of practice to prevent pressure injuries from worsening for resident R104, including lack of weekly wound measurements, treatment documentation, and timely physician notification. | Level of Harm - Actual harm |
| Failure to provide appropriate catheter care and prevent urinary tract infections for residents R104 and R14, including catheter bag on floor and improper hand hygiene during catheter care. | Level of Harm - Minimal harm or potential for actual harm |
| Insufficient nursing staff to meet resident needs, resulting in delayed care, missed showers, long call light response times, and family members assisting with feeding. | Level of Harm - Minimal harm or potential for actual harm |
| Feeding assistants assisting residents without completing a state-approved training course, including housekeeping staff assisting with dining. | Level of Harm - Minimal harm or potential for actual harm |
| Medication administration errors including improper administration of nasal spray and crushing enteric coated tablets. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store, prepare, distribute and serve food in accordance with professional standards, including thawing raw hamburger in hot water and stacking undried food storage bins. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to properly dispose of garbage and refuse, with observed litter including gloves, face shield, and used feminine hygiene products near the dumpster. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 4
Medication errors: 2
Facility census: 104
Staffing ratios: 1
Call light response time: 55
Call light response time: 128
Call light response time: 32
Call light response time: 37
Call light response time: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SW G | Social Worker | Interviewed regarding lost hearing aid grievance for resident R265 |
| NHA A | Nursing Home Administrator | Interviewed regarding grievance process, restraint use, staffing, shower scheduling, catheter bag placement, medication errors, feeding assistant training, food safety, and garbage disposal |
| LPN C | Licensed Practical Nurse | Interviewed regarding use of body pillow as restraint for resident R97 |
| CNA F | Certified Nursing Assistant | Interviewed regarding use of body pillow as restraint for resident R97 |
| CNA P | Certified Nursing Assistant | Interviewed regarding staffing shortages and missed showers |
| CNA S | Certified Nursing Assistant | Interviewed regarding staffing shortages, missed showers, call light response, and resident complaints |
| RN H | Registered Nurse | Interviewed regarding staffing shortages and missed showers |
| DON B | Director of Nursing | Interviewed regarding shower documentation, call light response, catheter care, medication errors, feeding assistant training, and staffing |
| CNA L | Certified Nursing Assistant | Observed performing catheter care without proper hand hygiene |
| MT T | Medication Technician | Observed administering nasal spray incorrectly and crushing enteric coated tablet |
| FM V | Family Member | Interviewed regarding staffing shortages and feeding assistance |
| HSK U | Housekeeping Staff | Reported assisting residents with dining due to short staffing |
| RN R | Registered Nurse | Interviewed regarding housekeeping staff assisting with dining |
| HC D | Head Cook | Interviewed regarding thawing raw hamburger in hot water |
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