Inspection Report Summary
The most recent inspection on June 6, 2025, found deficiencies related to the facility’s failure to develop and implement a complete, person-centered care plan for one resident. Earlier inspections showed a pattern of issues including inadequate resident transfers, multiple care and safety deficiencies such as fall prevention, medication management, infection control, and food safety. Complaint investigations identified problems with timely medical care after falls, incomplete abuse investigations, infection control lapses, and failure to offer influenza immunizations, though most complaints were unsubstantiated beyond these findings. Enforcement actions or fines were not listed in the available reports. The facility’s inspection history shows ongoing challenges with care planning and safety practices, with no clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 6, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to assess whether the facility developed and implemented a comprehensive, person-centered care plan for residents.
Findings
The facility failed to develop a person-centered comprehensive care plan for one resident (R1), lacking measurable timetables and actionable approaches for staff to follow. The care plan and resident profile contained multiple problem areas with blank approaches, and staff interviews confirmed the absence of clear care instructions.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions.
Report Facts
Residents affected: 3
Date of OBRA quarterly assessment: Apr 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA C) | Interviewed regarding resident's care plans and approaches; unable to find approaches for R1 | |
| Certified Nursing Assistant (CNA D) | Interviewed regarding resident's care plans and approaches; indicated review of resident profiles for care approaches | |
| Nursing Home Administrator (NHA A) | Acknowledged absence of approaches in R1's care plan and resident profile | |
| Director of Nursing (DON B) | Acknowledged absence of approaches in R1's care plan and resident profile |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 3, 2025
Visit Reason
The inspection was conducted to assess compliance with safety regulations regarding resident transfers and accident hazard prevention in the nursing home.
Findings
The facility failed to ensure that residents R5 and R6 were transferred according to their care plans requiring two staff members, as CNA C reported performing solo transfers despite care plans specifying two-person assistance. This posed a minimal harm or potential for actual harm to residents.
Deficiencies (1)
Failure to ensure resident environment remained free of accident hazards and provide adequate supervision to prevent accidents, specifically related to improper transfer assistance for residents R5 and R6.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Reported performing solo transfers for residents requiring two staff members assist. | |
| DON B | Confirmed expectation of two staff members assisting with resident transfers as per care plans. |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 9, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights, safety, pressure ulcer care, fall prevention, pain management, medication administration, infection control, staffing, food safety, and immunization policies at Sun Prairie Senior Living.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate housekeeping, improper pressure ulcer care, insufficient fall prevention measures, inadequate pain management, medication errors, lack of required RN coverage, food safety violations, infection control lapses, and failure to properly offer influenza vaccinations.
Deficiencies (10)
Failure to ensure resident R13 was treated with dignity and respect when transferred to breakfast in pajamas despite her expressed preference not to.
Failure to maintain a safe, clean, comfortable environment for resident R18, including inadequate housekeeping and dust accumulation.
Failure to provide appropriate pressure ulcer care for resident R382, including lack of pressure relieving cushion during wheelchair use and improper use of air mattress without manufacturer guidance.
Failure to provide adequate supervision and assistance to prevent falls for resident R16, including failure to document falls, notify physician and power of attorney, and implement individualized interventions.
Failure to provide safe and appropriate pain management for resident R182, including failure to obtain narcotic orders timely and failure to address medication refusals.
Failure to ensure a Registered Nurse was on duty for 8 consecutive hours on January 1, 2025.
Medication error rate of 16% due to timing errors and failure to provide meal within required timeframe for insulin administration affecting residents R11, R14, and R5.
Failure to maintain a safe and sanitary food preparation environment including staff not wearing hair restraints, lack of dishwasher temperature monitoring records, dented cans in circulation, expired food items, and unlabeled food removed from original packaging.
Failure to implement an effective infection prevention and control program including improper use of PPE when caring for resident R16 on enhanced barrier precautions, failure to perform contact tracing and testing during COVID-19 outbreak, and failure to track staff illnesses adequately.
Failure to offer influenza immunizations to resident R16 during the current flu season despite refusal on admission and lack of documentation of subsequent offers.
Report Facts
Medication errors: 3
Falls: 6
BIMS score: 2
BIMS score: 14
BIMS score: 10
BIMS score: 5
BIMS score: 15
BIMS score: 9
Medication administration time: 102
Medication administration time: 111
Insulin administration to meal delay: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Named in dignity issue for transferring resident R13 to dining room in pajamas |
| RN N | Registered Nurse | Interviewed regarding pressure ulcer care for resident R382 |
| LPN L | Licensed Practical Nurse | Interviewed regarding pressure ulcer care and infection control |
| DON B | Director of Nursing | Interviewed regarding dignity issue, pressure ulcer care, fall prevention, pain management, RN coverage, medication errors, infection control, and immunizations |
| CRN J | Clinical Registered Nurse | Interviewed regarding dignity issue, fall prevention, and insulin administration |
| LPN K | Licensed Practical Nurse | Observed administering insulin late and interviewed about insulin administration timing |
| LPN S | Licensed Practical Nurse | Interviewed regarding pain management for resident R182 |
| RN R | Registered Nurse | Interviewed regarding pain management for resident R182 |
| CNA T | Certified Nursing Assistant | Interviewed regarding pain complaints of resident R182 |
| Director of Food Services C | Interviewed regarding food safety and dishwasher monitoring | |
| Assistant Director of Food Service D | Interviewed regarding food safety and dishwasher monitoring | |
| CNA E | Certified Nursing Assistant | Observed providing care without PPE to resident R16 |
| CNA M | Certified Nursing Assistant | Observed texting on phone and assisting resident R16 without hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate assessment and timely medical care following a resident's fall and change in condition.
Complaint Details
The complaint investigation focused on the facility's failure to provide timely and appropriate medical care to resident R19 following a fall and change in condition on 10/21/23, including failure to assess and notify the physician, and failure to transfer to hospital in a timely manner. The investigation also included review of care for resident R5 related to range of motion, food safety practices, staffing data submission, and influenza immunization offering.
Findings
The facility failed to ensure timely and appropriate medical care for resident R19 after an unwitnessed fall on 10/21/23, including failure to properly assess range of motion and changes in ambulation, and delayed hospital transfer. Additionally, the facility failed to follow physician orders for range of motion care for resident R5, and did not ensure proper food safety and labeling practices. The facility also failed to submit mandatory staffing data for a prior quarter and did not offer influenza immunization to a resident as required.
Deficiencies (5)
Failure to provide appropriate assessment and timely medical care for resident R19 after fall and change in condition.
Failure to provide appropriate care to maintain and/or improve range of motion for resident R5, including failure to follow physician orders for splint application and ROM exercises.
Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including dirty equipment, unlabeled and expired foods, and inadequate sanitization.
Failure to electronically submit complete and accurate direct care staffing information based on payroll data for the 3rd quarter of 2022.
Failure to offer influenza immunization to resident R21 as required by facility policy.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 23
Residents affected: 23
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN L | Registered Nurse | Nurse who responded to R19's fall and documented initial assessment. |
| RN M | Registered Nurse | Night shift nurse on 10/21/23 who monitored R19 overnight. |
| RN N | Registered Nurse | AM nurse on 10/22/23 who cared for R19 and reported refusal of care. |
| LPN J | Licensed Practical Nurse | Nurse familiar with R5's care and contractures, provided insight on care practices. |
| DON B | Director of Nursing | Provided information on facility policies, education, and vaccine documentation. |
| RN O | Corporate Registered Nurse | Conducted investigation of R19's fall and care. |
| OT K | Occupational Therapist | Provided therapy services and recommendations for R5's contractures. |
| FSD D | Food Service Director | Provided information on food safety deficiencies. |
| NHA A | Nursing Home Administrator | Provided information on staffing data submission and vaccine offering. |
| ADON, IP C | Assistant Director of Nursing, Infection Preventionist | Provided information on vaccine offering and infection prevention. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 22, 2022
Visit Reason
The inspection was conducted in response to complaints and allegations regarding abuse, inadequate fall assessments and interventions, infection control deficiencies, and antibiotic stewardship concerns at Sun Prairie Senior Living.
Complaint Details
The complaint investigation focused on allegations of staff being rude and telling a resident not to use her call light, inadequate fall assessments and interventions for residents who removed alarms, infection control deficiencies during a COVID outbreak including staff screening failures, and lack of antibiotic stewardship documentation and monitoring.
Findings
The facility failed to thoroughly investigate abuse allegations, did not adequately assess and intervene for residents who removed chair/bed alarms after falls, lacked a comprehensive infection prevention and control program including proper staff screening and surveillance, and did not implement an effective antibiotic stewardship program with proper documentation and monitoring of antibiotic use.
Deficiencies (4)
Failure to ensure thorough investigation of abuse allegations for one resident.
Failure to provide adequate assessment and care plan interventions after falls for residents who remove chair/bed alarms.
Failure to establish and maintain an infection prevention and control program including daily surveillance, proper staff screening, and PPE disposal.
Failure to implement an antibiotic stewardship program including antibiotic use protocols and monitoring, with missing documentation for antibiotic treatments.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 23
Residents affected: 4
Date of fall: 2022
Date of fall: 2022
Date of survey: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SW C | Social Worker | Designee/grievance officer who completed the investigation for resident R15's grievance |
| DON B | Director of Nursing | Interviewed regarding fall assessments and alarm use for residents R15 and R11 |
| ADON/IC D | Assistant Director of Nursing/Infection Control | Interviewed regarding fall incident, infection control practices, staff screening, and antibiotic stewardship |
| RT P | Receptionist | Interviewed regarding staff and visitor screening process |
| NHA A | Nursing Home Administrator | Interviewed regarding infection control and antibiotic stewardship processes |
| CNA K | Certified Nursing Assistant | Mentioned in infection control deficiency for working without screening and testing positive for COVID |
| CNA J | Certified Nursing Assistant | Mentioned in infection control deficiency for not being tested for COVID prior to return to work |
| CNA H | Certified Nursing Assistant | Observed removing PPE improperly in resident's room |
Viewing
Loading inspection reports...
