Inspection Reports for
St Camillus
10101 W WISCONSIN AVE, WAUWATOSA, WI, 53226-
Back to Facility ProfileInspection Report — Jul 8, 2025
Complaint Investigation
Deficiencies: 1
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.
Complaint Details
The complaint involved two residents with allegations of abuse and injuries of unknown origin. The facility did not report the verbal abuse allegation involving R1 to law enforcement. For R2, a fracture of the 5th metatarsal was confirmed by X-ray on 6/14/25 but was not reported to the state agency until 6/16/25. The delay was attributed to late notification from the night shift supervisor. The facility acknowledged these reporting failures and initiated staff education and corrective actions.
Findings
The facility failed to timely report suspected abuse and significant injuries of unknown origin to the state agency and law enforcement. Specifically, allegations of verbal abuse toward resident R1 were not reported to law enforcement, and a fracture injury to resident R2 was reported late due to communication delays within the facility.
Deficiencies (1)
F0609: The facility did not timely report suspected abuse, neglect, or theft and failed to report the results of investigations to proper authorities as required by federal regulations.
Report Facts
Date of injury report delay: 2
Number of residents involved: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Acknowledged delay in reporting injury and discussed corrective actions with surveyors. |
| DON-B | Director of Nursing | Initiated investigation of abuse allegations and monitored resident R1. |
| RN-E | Registered Nurse | Night shift supervisor who delayed notifying administration of R2's fracture. |
| LPN-D | Licensed Practical Nurse | Assessed R2's bruised and swollen foot and reported injury to RN-C. |
| RN-C | Registered Nurse | Assessed R2's injury, ordered x-ray, and updated administration. |
| PTA-J | Physical Therapy Assistant | Witnessed resident R1 upset after alleged verbal abuse and provided statements. |
| CNA-I | Certified Nursing Assistant | Alleged to have verbally abused resident R1 during care. |
Inspection Report — Apr 14, 2025
Complaint Investigation
Deficiencies: 5
Date: Apr 14, 2025
Visit Reason
The inspection was conducted due to complaint investigations involving allegations of sexual misconduct and abuse, as well as concerns about resident safety, infection control, and bed rail safety.
Complaint Details
The complaint investigation focused on allegations of sexual abuse involving resident R1, multiple falls and injuries involving resident R24, infection control concerns including improper use of personal protective equipment and hand hygiene for residents R23 and R392, and safety concerns regarding bed rails for residents R1, R24, R28, and R392.
Findings
The facility failed to thoroughly investigate allegations of sexual abuse involving a resident (R1), did not adequately prevent falls and injuries for a resident (R24) with multiple falls and fractures, failed to properly assess and maintain bed rails for safety and consent, and did not fully implement infection prevention and control measures including enhanced barrier precautions and hand hygiene.
Deficiencies (5)
F0610: The facility did not ensure all allegations of potential abuse involving R1 were thoroughly investigated, missing key interviews and relevant questions.
F0689: The facility failed to provide adequate supervision and fall prevention interventions for R24, who had 11 falls resulting in multiple injuries including rib fractures.
F0700: The facility did not assess risks, obtain informed consent, or conduct quarterly evaluations for bed rails used by residents R1 and R24, and failed to maintain a care plan for repositioning bars.
F0880: The facility failed to establish and maintain an effective infection prevention and control program, including lack of a comprehensive water management plan and failure to follow enhanced barrier precautions and hand hygiene protocols for resident R23 and R392.
F0909: The facility did not conduct regular inspections of bed frames, mattresses, and bed rails to identify entrapment risks for residents R1, R24, R28, and R392, and maintenance inspections were only done on an as-needed basis.
Report Facts
Facility Reported Incidents (FRI): 3
Falls: 11
Shifts not completed: 33
Fall Risk Score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Named in discussions regarding sexual abuse investigations, fall prevention, infection control, and bed rail safety |
| DON-B | Director of Nursing | Named in discussions and interviews regarding sexual abuse investigations, fall prevention, infection control, and bed rail safety |
| DSS-P | Director of Social Services | Interviewed regarding investigation procedures for abuse allegations |
| RN-E | Registered Nurse | Mentioned in relation to missing interview during sexual abuse investigation |
| ESD-AA | Environmental Services Director | Interviewed regarding water management program and bed rail inspections |
| RN-Z | Registered Nurse | Observed not following enhanced barrier precautions during medication administration |
| LPN-Y | Licensed Practical Nurse | Observed not following enhanced barrier precautions during medication administration |
| RN-W | Registered Nurse Manager | Observed during wound care with hand hygiene concerns |
Inspection Report — Apr 10, 2025
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
Surveyors completed a complaint investigation at St. Camillus.
Complaint Details
The complaint was unsubstantiated.
Findings
No deficiencies were identified and the complaint was unsubstantiated.
Inspection Report — Feb 20, 2025
Routine
Census: 75
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
Surveyor completed a standard survey and two complaint investigations at St. Camillus Assisted Living.
Complaint Details
Two complaints were investigated and both were unsubstantiated.
Findings
No deficiencies were identified during the survey. Two complaints were investigated and found to be unsubstantiated.
Inspection Report — Feb 9, 2024
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
Surveyor conducted a complaint survey at St Camillus to investigate a complaint.
Complaint Details
Complaint was unsubstantiated.
Findings
The complaint was unsubstantiated and no deficient practice was identified during the survey.
Inspection Report — Feb 1, 2024
Complaint Investigation
Deficiencies: 6
Date: Feb 1, 2024
Visit Reason
Investigation of allegations of abuse and injuries of unknown origin involving two residents sharing a room, including failure to report incidents to the State Agency.
Complaint Details
Complaint investigation focused on abuse and injuries of unknown origin involving two residents sharing a room. Multiple incidents of physical abuse and injuries were documented but not reported to the State Agency. The facility's failure to report and monitor these incidents was confirmed by interviews with the Nursing Home Administrator and staff.
Findings
The facility failed to report multiple incidents of resident-to-resident abuse and injuries of unknown origin to the State Agency. Several injuries and altercations between two residents were documented, with inadequate investigation, monitoring, and reporting. The facility also failed to ensure safe medication administration and monitoring of psychotropic medications for adverse effects. Food safety and infection prevention deficiencies were noted in the kitchen.
Deficiencies (6)
F0600: Facility failed to protect residents from abuse including physical and sexual abuse, and failed to report incidents and injuries of unknown origin to the State Agency as required.
F0755: Facility failed to ensure safe medication administration by leaving medications at a resident's bedside without a physician order or assessment for self-administration.
F0757: Facility failed to monitor for adverse reactions and effectiveness of high-risk medications including opioids and psychotropics for two residents.
F0759: Facility had a 23% medication error rate during observations, including crushing medications without orders and administering wrong medications.
F0804: Facility failed to ensure food safety practices including proper cooling methods, sanitizing solution testing, and cleanliness of equipment such as can opener.
F0812: Facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including improper cooling, sanitizing, and food handling practices.
Report Facts
Medication error rate: 23
Bruise size: 16
Bruise size: 12
Bruise size: 3
Medication dosage: 20
Medication dosage: 0.5
Medication dosage: 25
Medication error count: 6
Medication administration opportunities: 26
Food holding temperature: 45
Food holding temperature: 52
Inspection Report — Jun 27, 2023
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home survey conducted by the Centers for Medicare & Medicaid Services.
Findings
No health deficiencies were found during the survey.
Inspection Report — Oct 3, 2022
Routine
Deficiencies: 2
Date: Oct 3, 2022
Visit Reason
The inspection was conducted to evaluate medication administration practices and infection prevention and control program compliance at St Camillus Health Center.
Findings
The facility had a medication error rate of 10.53%, exceeding the acceptable threshold of 5%. Medication errors included incorrect dosages and administration of discontinued medications. Additionally, the facility failed to maintain proper infection prevention practices, including staff handling medications with bare hands without hand hygiene.
Deficiencies (2)
F 0759: The facility medication error rate was 10.53%, exceeding the 5% threshold. Resident R17 did not receive Vitamin D or Calcium Carbonate as ordered. Resident R238 received Diclofenac gel without using the dosing card and was given a discontinued Lidocaine 5% patch without an active order.
F 0880: The facility did not maintain an infection prevention and control program. Staff were observed handling medications with bare hands without washing or sanitizing before medication preparation and administration.
Report Facts
Medication error rate: 10.53
Medication error rate threshold: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)-C | Observed preparing and administering medications incorrectly, including medication errors and poor hand hygiene | |
| Licensed Practical Nurse (LPN)-D | Observed applying medications incorrectly, including applying discontinued Lidocaine patch and not using dosing card | |
| Nursing Home Administrator (NHA)-A | Advised of medication errors and infection control concerns | |
| Director of Nursing (DON)-B | Advised of medication errors and infection control concerns |
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