Deficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 8, 2025
Visit Reason
The inspection was conducted due to allegations of abuse and injuries of unknown origin involving two residents (R1 and R2) at St Camillus Health Center. The investigation focused on the facility's failure to timely report these incidents to the state agency and law enforcement as required.
Complaint Details
The complaint investigation involved two residents: R1, who was verbally abused by a CNA and whose abuse was not reported to law enforcement; and R2, who sustained a fracture to the right foot that was not reported to the state agency within 24 hours. The allegations were substantiated with evidence from interviews, medical records, and facility self-reports.
Findings
The facility failed to report suspected abuse of resident R1 to law enforcement and delayed reporting a significant injury (fracture) of resident R2 to the state agency. Investigations revealed verbal abuse by a CNA towards R1 and a fracture in R2's foot that was not reported within the required timeframe. The facility acknowledged errors in reporting and initiated staff education on reporting requirements.
Deficiencies (2)
Failure to timely report suspected abuse of resident R1 to law enforcement.
Failure to report significant injury (fracture) of resident R2 within 24 hours to the state agency.
Report Facts
Residents affected: 2
Date of injury report delay: 2
Size of bruise: 120
BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Acknowledged delay in reporting R2's injury and failure to report R1's abuse to law enforcement; provided education to staff. |
| Director of Nursing (DON)-B | Director of Nursing | Started investigation immediately upon notification of R1's abuse; involved in interviews and acknowledged concerns. |
| Certified Nursing Assistant (CNA)-I | Certified Nursing Assistant | Alleged to have verbally abused resident R1. |
| Physical Therapy Assistant (PTA)-J | Physical Therapy Assistant | Witnessed R1 upset after alleged abuse and provided statements during investigation. |
| Registered Nurse (RN)-E | Registered Nurse | Assessed R2's injury and failed to notify NHA-A of fracture in a timely manner. |
| Licensed Practical Nurse (LPN)-D | Licensed Practical Nurse | Assessed R2's bruised and swollen foot and reported injury to RN-C. |
| Registered Nurse (RN)-C | Registered Nurse | Assessed R2's injury, ordered x-ray, and updated administration. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 14, 2025
Visit Reason
The inspection was conducted due to allegations of sexual misconduct involving resident R1 and concerns about accident hazards and supervision related to resident falls, including multiple falls and injuries sustained by resident R24.
Complaint Details
The complaint investigation focused on allegations of sexual misconduct involving resident R1, with findings that the facility did not thoroughly investigate these allegations. Additionally, the investigation included concerns about falls and accident hazards affecting resident R24 and others, with findings of inadequate supervision and safety measures.
Findings
The facility failed to thoroughly investigate allegations of sexual abuse involving resident R1, including not interviewing the resident's roommate or relevant staff. Resident R24 experienced multiple falls, including one resulting in multiple rib fractures, with inadequate individualized fall prevention plans and supervision. The facility also failed to regularly inspect bed rails for safety and did not ensure appropriate sling use for resident transfers, resulting in immediate jeopardy for resident safety.
Deficiencies (4)
Facility did not ensure all allegations involving potential abuse of resident R1 were thoroughly investigated, including failure to interview resident's roommate and relevant staff.
Facility failed to provide adequate supervision and accident hazard prevention for resident R24, who had 11 falls including one with multiple rib fractures, and did not develop individualized fall prevention plans.
Facility failed to ensure regular inspection and maintenance of bed rails for residents R1, R24, R28, and R392, risking entrapment and safety hazards.
Facility failed to ensure appropriate sling use for resident transfers, resulting in resident R291 falling from a sling and sustaining serious head injuries.
Report Facts
Facility reported incidents involving R1: 3
Number of falls for resident R24: 11
Staples received by resident R291: 10
Residents observed with bilateral enabler bars: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Interviewed regarding investigation of sexual abuse allegations and fall prevention concerns |
| DON-B | Director of Nursing | Interviewed regarding investigation of sexual abuse allegations, fall prevention, and bed rail safety |
| DSS-P | Director of Social Services | Interviewed regarding investigation process for abuse allegations |
| RN-E | Registered Nurse | Staff member whose statement was not obtained during sexual abuse investigation |
| LPN-DD | Licensed Practical Nurse | Documented fall incident involving resident R24 |
| RN-CC | Registered Nurse | Documented admission and fall details for resident R24 |
| RN-GG | Registered Nurse | Documented fall incidents and injuries for resident R24 |
| LPN-F | Licensed Practical Nurse | Documented pain complaints and injury assessment for resident R24 |
| ESD-AA | Environmental Services Director | Interviewed regarding bed rail inspection and maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 14, 2025
Visit Reason
The inspection was conducted due to complaints involving allegations of sexual abuse and concerns about resident safety and care, including falls and infection control.
Complaint Details
The complaint investigation involved allegations of sexual abuse against resident R1, multiple falls and injuries involving resident R24, improper transfer equipment use causing injury to resident R291, infection control deficiencies involving residents R23 and R392, and safety concerns with bed rails for residents R1, R24, R28, and R392.
Findings
The facility failed to thoroughly investigate allegations of sexual abuse involving resident R1, did not ensure adequate supervision and fall prevention for resident R24 who sustained multiple falls and injuries including rib fractures, failed to properly assess and use appropriate slings for resident transfers leading to injury of resident R291, did not maintain proper infection control practices including enhanced barrier precautions for resident R23 and R392, and did not regularly inspect bed rails for safety and entrapment risks for multiple residents.
Deficiencies (5)
Failure to thoroughly investigate allegations of sexual abuse involving resident R1.
Failure to provide adequate supervision and fall prevention for resident R24 resulting in multiple falls and rib fractures.
Failure to assess and provide appropriate slings for resident transfers, resulting in resident R291 falling and sustaining a subdural hematoma and laceration.
Failure to establish and maintain an infection prevention and control program, including improper use of personal protective equipment and lack of enhanced barrier precautions for residents with open wounds.
Failure to regularly inspect bed frames, mattresses, and bed rails for safety and entrapment risks for residents R1, R24, R28, and R392.
Report Facts
Facility reported incidents involving R1: 3
Falls: 11
Shifts not completed: 33
Fall risk evaluation score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Interviewed regarding sexual abuse investigations, fall prevention, infection control, and bed rail safety |
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding sexual abuse investigations, fall prevention, infection control, and bed rail safety |
| Director of Social Services (DSS)-P | Director of Social Services | Interviewed regarding investigation procedures for abuse allegations |
| Registered Nurse (RN)-E | Registered Nurse | Mentioned in relation to sexual abuse investigation and falls |
| Environmental Services Director (ESD)-AA | Environmental Services Director | Interviewed regarding water management program and bed rail inspections |
| Registered Nurse (RN)-Z | Registered Nurse | Observed administering medications without proper PPE |
| Licensed Practical Nurse (LPN)-Y | Licensed Practical Nurse | Observed administering medications without proper PPE |
| Certified Nursing Assistant (CNA)-K | Certified Nursing Assistant | Observed providing care without proper PPE |
| Registered Nurse Manager (RN)-W | Registered Nurse Manager | Observed during wound care with improper hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Feb 1, 2024
Visit Reason
The investigation was conducted due to allegations of abuse and injuries of unknown origin involving two residents sharing a room, including physical altercations and unexplained bruises.
Complaint Details
The complaint investigation focused on allegations of abuse and injuries of unknown origin involving two residents sharing a room. Multiple incidents of physical aggression, bruising, skin tears, and other injuries were documented but not reported to the State Agency. The facility did not monitor for psychosocial harm or update care plans accordingly.
Findings
The facility failed to report multiple incidents of abuse and injuries of unknown origin to the State Agency as required. Several injuries and altercations between two residents were documented, including punches, bruises, skin tears, and aggressive behaviors. The facility did not monitor psychosocial harm or update care plans accordingly.
Deficiencies (7)
Failure to timely report suspected abuse and injuries of unknown origin to the State Agency for two residents.
Failure to respond appropriately to all alleged violations related to abuse and injuries of unknown origin.
Failure to ensure accurate and safe administration of medication for one resident, including leaving medication at bedside without physician order or assessment.
Failure to monitor for adverse reactions or effectiveness of high-risk medications (opioids and psychotropics) for two residents.
Failure to ensure medication error rates are below 5%, including crushing medication without order and administering wrong medication.
Failure to ensure food and drink are palatable, attractive, and at safe and appetizing temperatures; including improper cooling methods, unclean can opener, and inadequate sanitizing solution testing.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards.
Report Facts
Medication error rate: 23
Bruise size: 16
Bruise size: 12
Bruise size: 3
Bruise size: 12
Bruise size: 7
Medication dosage: 0.5
Medication dosage: 25
Medication dosage: 20
Medication dosage: 81
Medication error count: 6
Medication administration opportunities: 26
Food temperature: 45
Food temperature: 52
Dishwasher rinse temperature: 179
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Interviewed regarding failure to report abuse and injuries, and medication monitoring |
| DON-B | Director of Nursing | Interviewed regarding medication administration and monitoring |
| LPN-F | Licensed Practical Nurse | Interviewed regarding medication administration errors and leaving medication at bedside |
| ADM-E | Assistant Dietary Manager | Interviewed regarding kitchen practices, food safety, and sanitizing solution testing |
Inspection Report
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for St Camillus Health Center, summarizing the results of a regulatory survey completed on 2023-06-27.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Oct 3, 2022
Visit Reason
The inspection was conducted to assess the facility's medication administration practices and infection prevention and control program, focusing on medication error rates and compliance with hand hygiene policies.
Findings
The facility had a medication error rate of 10.53%, exceeding the acceptable 5% threshold, with specific errors including incorrect medication administration and use of discontinued medications. Additionally, the facility failed to maintain proper infection prevention practices, as staff were observed handling medications with bare hands without washing or sanitizing.
Deficiencies (2)
Medication error rate was 10.53%, exceeding the 5% limit; R17 did not receive Vitamin D or Calcium Carbonate as ordered; R238 did not receive Diclofenac gel as ordered and received discontinued Lidocaine patch.
Facility staff touched medications with bare (ungloved) hands during medication pass observation, violating infection prevention and control policies.
Report Facts
Medication error rate: 10.53
Medication error count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-C | Licensed Practical Nurse | Observed preparing and administering medications incorrectly to R17 and R8, including handling medications with bare hands and incorrect dosing |
| LPN-D | Licensed Practical Nurse | Observed preparing and administering medications incorrectly to R238, including applying discontinued Lidocaine patch and not using dosing card for Diclofenac gel |
| NHA-A | Nursing Home Administrator | Advised of medication errors and infection control concerns on 10/03/2022 |
| DON-B | Director of Nursing | Advised of medication errors and infection control concerns on 10/03/2022 |
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