Inspection Report Summary
The most recent inspection on August 1, 2025, identified deficiencies related to the facility’s handling of a resident’s known behavioral issues and the lack of timely interventions, which resulted in a facial injury. Earlier inspections showed a range of issues including resident privacy and confidentiality, incomplete assessments during changes in condition, food storage and handling problems, failure to follow posted menus, and inadequate fall prevention measures substantiated by a complaint investigation. Prior reports also noted medication administration errors, improper use of restraints, and deficiencies in transfer notifications and infection control practices. Complaint investigations were mostly unsubstantiated except for one substantiated case involving falls due to inadequate supervision and failure to follow care plans. The inspection history shows ongoing challenges with resident care and safety interventions, with no clear pattern of overall improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 1, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to providing necessary behavioral health care and services to residents.
Findings
The facility failed to ensure that known behavioral issues of one resident, including kicking, hitting, grabbing, and rejection of care, were properly addressed through timely development and implementation of interventions. The resident sustained a facial injury during an incident related to aggressive behavior, and staff expectations regarding handling such behaviors were not fully met.
Deficiencies (1)
Failure to ensure known resident behaviors of kicking, hitting, grabbing, rejection of care were addressed with appropriate interventions for Resident #2.
Report Facts
Behavior occurrence days: 15
Behavior occurrence days: 11
Behavior occurrence days: 15
Behavior occurrence days: 7
BIMS score: 6
BIMS score: 4
Laceration size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Documented nurse's note regarding Resident #2's injury on 07/19/2025 |
| CNA A | Certified Nursing Assistant | Reported Resident #2 became combative and punched her during care on 07/19/2025 |
| Administrator | Provided interviews regarding Resident #2's behaviors and root cause analysis | |
| Director of Nursing | Director of Nursing | Provided interview on staff expectations for handling Resident #2's aggressive behavior |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 6, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, treatment and care, and food safety standards at St Ann Health and Rehabilitation Center.
Findings
The facility was found deficient in maintaining resident privacy and confidentiality, providing comprehensive assessments for residents with changes in condition, and adhering to professional standards for food storage and service. Specific issues included unattended medication records visible to others, incomplete assessments during a resident's change in condition, and improper food storage and handling practices.
Deficiencies (3)
Failed to maintain resident's right to personal privacy and confidentiality of medical records; medication administration record left unattended and visible in a common area.
Did not ensure a resident with a change in condition received a comprehensive assessment; vital signs were not obtained prior to hospital transfer.
Failed to store and serve food in accordance with professional standards; observed partially used and undated food items, lack of hair restraints on kitchen staff, and incomplete food temperature monitoring.
Report Facts
Residents reviewed: 12
Residents affected: 1
Residents affected: 1
Residents affected: 46
Residents affected: 48
Food items observed partially used: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-D | Registered Nurse | Named in privacy breach finding for leaving medication administration record unattended |
| RN-H | Registered Nurse | Named in incomplete assessment finding for not completing comprehensive assessment during resident's change in condition |
| NHA-A | Nursing Home Administrator | Informed of privacy and food safety concerns |
| DON-B | Director of Nursing | Interviewed regarding nursing expectations and agreed to conduct education on assessment deficiencies |
| FSD-C | Food Service Director | Interviewed about food storage and delivery practices |
| Cook-E | Cook | Interviewed about food temperature monitoring |
| DA-F | Dietary Aide | Observed not wearing beard restraint in kitchen |
| DA-G | Dietary Aide | Observed serving food without taking required temperatures |
Inspection Report
Census: 45
Deficiencies: 1
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to assess whether the facility ensured menus met the nutritional needs of residents, were prepared in advance, followed as posted, updated, reviewed by a dietician, and met resident needs.
Findings
The facility failed to ensure menus were followed and served as posted and on dietary tray cards, placing 45 residents at risk of dissatisfaction with their meals. Observations, interviews, and record reviews confirmed discrepancies between posted menus and actual meals served.
Deficiencies (1)
Facility failed to ensure menus were followed and served as posted and on dietary tray cards.
Report Facts
Residents affected: 45
BIMS score: 15
Menu item quantity: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding menu discrepancies and substitutions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was conducted due to concerns about inadequate supervision and failure to implement fall prevention interventions for residents, specifically related to two residents (R3 and R4) who experienced falls.
Complaint Details
The investigation was complaint-related, focusing on falls experienced by residents R3 and R4. The root causes included failure to follow care plans for fall prevention and improper transfer techniques. The complaint was substantiated with findings of inadequate interventions and supervision.
Findings
The facility failed to ensure adequate supervision and proper use of assistance devices to prevent falls for two residents. Resident R3 did not have fall interventions in place as per care plan, including lack of a bolstered mattress and body pillows, and the bedside table was not within reach. Resident R4 was transferred improperly by one staff member instead of two, resulting in a fall.
Deficiencies (1)
Failure to ensure adequate supervision and assistance devices to prevent falls for residents R3 and R4.
Report Facts
Residents reviewed for accidents: 3
Falls by R3: 5
Date of R3 fall: Jan 24, 2024
Date of R4 fall: Feb 21, 2024
BIMS score R3: 3
BIMS score R4: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Discussed the status and ordering issues related to R3's bolstered mattress and acknowledged concerns about fall interventions. |
| Assistant Director of Nursing (ADON)-C | Assistant Director of Nursing | Provided information about R3 and R4's falls, care plans, and interventions; educated staff about following care plans. |
| Certified Nursing Assistant (CNA)-D | Certified Nursing Assistant | Involved in transferring R4 during the fall incident and was educated about following the care plan. |
| Certified Nursing Assistant (CNA)-E | Certified Nursing Assistant | Described how R4 transfers using a Sit-to-Stand lift with assistance of two people. |
| Certified Nursing Assistant (CNA)-F | Certified Nursing Assistant | Frequently works with R3 and described expected fall prevention measures that were not in place. |
| Director of Nursing (DON)-B | Director of Nursing | Charted the Interdisciplinary Team review of R3's fall. |
Inspection Report
Routine
Deficiencies: 8
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to observe medication administration, infection control practices, restraint use, resident privacy during treatments, transfer and discharge notifications, and overall compliance with healthcare regulations.
Findings
The facility was found deficient in multiple areas including failure to provide privacy during medication administration, improper use and documentation of physical restraints, failure to notify residents and representatives of transfers with appeal rights, inadequate care for residents with limited range of motion, medication errors including incorrect timing and crushing of extended release medications, expired and unlabeled insulin pens, and improper disinfection of shared glucometers.
Deficiencies (8)
Failure to provide personal privacy during medication administration and blood sugar testing for residents R40 and R20 in the dining room.
Use of physical restraint (seat belt) on resident R35 without physician's order, care plan, consent, or ongoing monitoring.
Failure to provide timely and complete transfer/discharge notices including appeal rights to residents and representatives for 5 residents (R45, R51, R10, R30, R35).
Failure to provide appropriate care to maintain or improve range of motion for resident R35, including not using a rolled washcloth in the right hand as per care plan and therapy recommendations.
Medication error rate of 18.75% observed during medication pass, including insulin administered after meals, crushing of extended release medications, and incorrect antibiotic dosing for resident R51.
Failure to ensure residents are free from significant medication errors, including insulin administration after meals and crushing of extended release medications.
Failure to label insulin pens with date opened and use of expired insulin for residents R7, R17, R19, and R25.
Failure to properly disinfect shared glucometers between residents, using alcohol wipes instead of disinfectant bleach wipes effective against blood borne pathogens.
Report Facts
Medication error rate: 18.75
Residents affected by transfer notice deficiency: 5
Residents affected by insulin labeling deficiency: 4
Residents affected by glucometer disinfection deficiency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-G | Registered Nurse | Observed administering medications improperly and not providing privacy during medication administration |
| ADON-C | Assistant Director of Nursing | Interviewed regarding medication administration, restraint use, transfer notices, and glucometer disinfection |
| DON-B | Director of Nursing | Interviewed regarding medication errors, restraint use, and transfer notices |
| NHA-A | Nursing Home Administrator | Informed of deficiencies during exit meeting |
| RN-M | Registered Nurse | Informed about antibiotic transcription error for resident R51 |
| DON-J | Director of Nursing | Provided late entry note and information about antibiotic transcription error for resident R51 |
| RN-L | Registered Nurse | Vascular Surgery nurse providing information about resident R51's care |
| MD-N | Medical Director | Provided signed statement regarding resident R51's amputation cause |
| MD-K | Vascular Surgeon | Provided information about resident R51's vascular condition and amputation |
| CNA-H | Certified Nursing Assistant | Interviewed regarding care for resident R35's hand contractures |
| Therapy Director-I | Therapy Director | Provided therapy recommendations for resident R35 |
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