Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with medication labeling and storage requirements, specifically ensuring drugs and biologicals are labeled according to professional principles and stored securely.
Findings
The facility failed to ensure that drugs and biologicals were properly labeled and included expiration dates as required. Insulin pens and vials on one medication cart were either unlabeled or expired, posing a potential risk to residents.
Deficiencies (1)
Drugs and biologicals were not labeled in accordance with professional principles and included expired insulin on medication cart B.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse G | Licensed Practical Nurse | Reported on insulin labeling and expiration dates during inspection. |
| Nursing Home Administrator A | Nursing Home Administrator | Was informed of concerns regarding unlabeled and expired insulins. |
| Director of Nursing B | Director of Nursing | Was informed of concerns regarding unlabeled and expired insulins. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Sunrise Health Services nursing home.
Findings
The facility was found deficient in multiple areas including failure to implement residents' advance directives correctly, incomplete care plan revisions, improper catheter care, expired and unlabeled medications, failure to provide altered textured diet menu items as planned, unsanitary food storage and preparation practices, and inadequate hospice communication documentation.
Deficiencies (7)
Failure to ensure residents' right to formulate and implement advance directives, specifically a Do Not Resuscitate (DNR) order was not properly documented or followed for 1 of 18 residents reviewed.
Failure to develop and revise complete care plans within 7 days of comprehensive assessment and as needed, specifically care plan for abdominal binder use was not revised for 1 of 18 residents reviewed.
Failure to provide appropriate catheter care, with catheter collection bag and tubing observed lying on the floor without barrier for 1 resident reviewed.
Failure to ensure drugs and biologicals were labeled and stored properly; insulin pens and vials were unlabeled and expired in medication carts.
Failure to follow menus for residents receiving altered textured diets; seven residents did not receive the dinner roll as stated on the menu.
Failure to maintain food and beverages in a sanitary manner; unsanitary conditions observed in kitchenette refrigerators and improper thermometer sanitation during food temperature checks.
Failure to ensure hospice visit notes were readily available and updated in the medical record and hospice binder for 1 of 3 residents reviewed for hospice services.
Report Facts
Residents reviewed for advance directives: 18
Residents reviewed for care plans: 18
Residents receiving altered textured diets: 7
Residents reviewed for hospice services: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-F | Registered Nurse | Interviewed regarding resident code status and DNR bracelet policy |
| LPN-G | Licensed Practical Nurse | Interviewed regarding resident code status, abdominal binder use, catheter care, and medication cart insulin labeling |
| DON-B | Director of Nursing | Interviewed regarding multiple deficiencies including advance directives, care plans, catheter care, medication concerns, menu issues, and hospice communication |
| LPNUM-D | Licensed Practical Nurse Unit Manager | Interviewed regarding care plan revisions, abdominal binder use, catheter care, and hospice binder location |
| CNA-H | Certified Nursing Assistant | Interviewed regarding abdominal binder use for resident R2 |
| CNA-I | Certified Nursing Assistant | Interviewed regarding abdominal binder use for resident R2 |
| DA-M | Dietary Aide | Observed serving meals and food temperature taking |
| DM-K | Dietary Manager | Interviewed regarding menu and food storage deficiencies |
| UM-D | Unit Manager | Interviewed regarding hospice binder location and communication |
| CNA-J | Certified Nursing Assistant | Interviewed regarding communication with hospice provider |
| Nursing Home Administrator-A | Administrator | Interviewed regarding medication labeling and expiration concerns |
| Senior President of Success-C | Senior Executive | Interviewed regarding menu and hospice communication concerns |
| Regional Director-L | Regional Director | Interviewed regarding kitchen staff education and food preparation policies |
Inspection Report
Census: 42
Deficiencies: 1
Date: Jul 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights to access their personal funds managed by the facility.
Findings
The facility did not ensure residents had access to their personal funds when requested, specifically lacking petty cash funds during evenings, weekends, and holidays. Staff interviews revealed no petty cash fund was maintained for off-hours withdrawals, and there was no posted information about banking hours or withdrawal availability.
Deficiencies (1)
Facility did not ensure residents had access to their personal funds when requested, lacking petty cash funds during evenings, weekends, or holidays.
Report Facts
Residents with personal funds managed by facility: 42
Bank visits per month: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BOM-C | Business Office Manager | Interviewed regarding management of residents' personal funds and petty cash availability |
| SSC-D | Social Services Coordinator | Interviewed regarding residents' access to personal funds and petty cash availability |
| Administrator-A | Administrator | Interviewed regarding residents' access to personal funds and petty cash availability |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 19, 2025
Visit Reason
The inspection was conducted based on complaints and concerns regarding staff qualifications for CPR, care and treatment of residents, pressure injury care, accident prevention, pharmaceutical services, and behavioral health training.
Complaint Details
The complaint investigation included concerns about CPR certification, care and treatment of residents, pressure injury prevention and treatment, accident prevention, pharmaceutical services, and behavioral health training. Immediate jeopardy was identified related to pressure injury care for resident R2 and was removed during the survey.
Findings
The facility failed to ensure staff were qualified and certified for CPR, did not provide appropriate treatment and care for residents including risk factor identification and intervention, failed to prevent and treat pressure injuries timely, did not provide adequate supervision to prevent accidents, failed to provide pharmaceutical services meeting resident needs, and did not provide required behavioral health training to staff.
Deficiencies (6)
Staff were not qualified to provide CPR and were unaware of CPR certification status; LPN-G performed CPR without current certification.
Facility did not ensure appropriate treatment and care for resident R1, failing to recognize risk factors related to knee brace slipping and failed surgical repair.
Facility did not ensure residents with pressure injuries or at risk received necessary treatment and services; delayed treatment orders and failure to offload heels were noted for resident R2.
Facility did not ensure adequate supervision and assistance devices to prevent accidents; resident R5 had an unwitnessed fall while toileting despite requiring assistance.
Facility did not provide pharmaceutical services to meet resident R2's needs; sodium bicarbonate order was not picked up and medication was left for family to administer.
Facility did not ensure 7 of 7 randomly selected staff and 1 contracted employee received required behavioral health training.
Report Facts
Residents with psychiatric diagnosis: 57
Pressure injury measurements: 4.5
Pressure injury measurements: 1.9
Pressure injury measurements: 2.4
Pressure injury measurements: 1.8
Pressure injury measurements: 2.2
Pressure injury measurements: 0.4
Pressure injury measurements: 0.7
Pressure injury measurements: 1
Pressure injury measurements: 2.5
Pressure injury measurements: 1.2
Pressure injury measurements: 1.7
Fall date: 2024
Fall risk assessment dates: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-G | Licensed Practical Nurse | Performed CPR on resident R3 without current CPR certification; involved in medication administration issues for resident R2. |
| UM-D | Unit Manager | Documented CPR event for resident R3; involved in wound care and pressure injury management for resident R2; acknowledged concerns regarding fall and supervision of resident R5. |
| DON-B | Director of Nursing | Interviewed regarding CPR certification, pressure injury care, and fall risk assessments; acknowledged concerns. |
| Wound NP-Q | Wound Nurse Practitioner | Assessed and treated pressure injuries for resident R2; provided wound care orders. |
| LPN-J | Licensed Practical Nurse | Received and documented nephrologist's order for sodium bicarbonate increase for resident R2. |
| LPN-N | Licensed Practical Nurse | Responded to resident R5's fall and notified unit manager; described fall circumstances. |
| UM-D | Unit Manager | Acknowledged concerns about fall risk assessments and post-fall assessments for resident R5. |
| NHA-A | Nursing Home Administrator | Acknowledged concerns about fall risk assessments and behavioral health training deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 1, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to notify resident representative of new treatment, inadequate care and monitoring of a resident's fracture and painful toe, a resident fall resulting in death, failure to provide appropriate dementia care, and failure to provide timely therapy services.
Complaint Details
The complaint investigation revealed substantiated findings of failure to notify resident representative, inadequate care and monitoring of a resident's fracture and painful toe, a fall from bed resulting in death due to environmental and supervision failures, inadequate dementia care including lack of assessments and care plan revisions, and failure to provide timely therapy services as ordered.
Findings
The facility failed to notify a resident's power of attorney about new treatments, did not consistently monitor a resident's fracture and painful toe, and lacked a care plan for these conditions. A resident fell from bed resulting in death due to failure to maintain a low bed position and provide adequate supervision. The facility did not provide appropriate dementia care including comprehensive behavior assessments and trauma assessments. Therapy services were not provided timely as ordered by physicians. Immediate jeopardy was identified related to the fall and dementia care but was removed after corrective actions.
Deficiencies (5)
Failure to notify resident representative when a new treatment was ordered for a resident.
Failure to provide appropriate treatment and care for a resident with a fracture and painful toe, including lack of consistent monitoring and care plan.
Failure to ensure a resident was free from accident hazards and provided adequate supervision to prevent a fall from bed resulting in death.
Failure to provide appropriate treatment and services for a resident with dementia and behavioral symptoms, including lack of comprehensive assessment and care plan revisions.
Failure to provide timely therapy services as ordered for a resident, including lack of evaluation and screening after hospital readmission.
Report Facts
Deficiencies cited: 5
BIMS score: 7
BIMS score: 3
Bed height: 30
Bed height: 7
Bed height: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Involved in straight catheterization attempt and noted resident hit elbow |
| RN ADON O | Registered Nurse/Assistant Director of Nursing | Discussed care plan and monitoring for resident with fracture |
| NHA A | Nursing Home Administrator | Notified of immediate jeopardy and involved in corrective action plan |
| DON B | Director of Nursing | Notified of immediate jeopardy and involved in corrective action plan |
| CNA P | Certified Nursing Assistant | Involved in care and holding resident during catheterization attempt |
| NP CC | Nurse Practitioner | Provided psychiatric care and medication management for resident |
| PT I | Physical Therapist | Provided therapy treatment and noted lack of evaluation after hospital return |
Inspection Report
Deficiencies: 2
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to investigate the facility's compliance with policies regarding residents returning to the nursing home after hospitalization or therapeutic leave, specifically focusing on one resident (R141) who went out on therapeutic leave and was not permitted to return.
Findings
The facility failed to ensure that resident R141 was allowed to return after therapeutic leave as per a written policy, which the facility did not have. The resident was out on pass with her husband but did not return as scheduled, and the facility ultimately discharged her without a formal discharge plan or bed hold policy. Communication attempts were made but unsuccessful, and the facility acknowledged lacking a policy on bed hold or therapeutic leave.
Deficiencies (2)
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Investigate need for special equipment, home health services, lifeline, outpatient therapy, physical follow up, resources, etc. Make referrals as needed.
Report Facts
Residents Affected: 1
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BOM D | Business Office Manager | Named in communication and findings related to resident R141's therapeutic leave and discharge |
| Administrator A | Administrator | Interviewed regarding resident R141's discharge and facility policies |
| Social Worker E | Social Worker | Involved in communication attempts and care conference for resident R141 |
| Social Worker F | Social Worker | Involved in communication attempts regarding resident R141 |
| Director of Nursing B | Director of Nursing | Involved in communication attempts and interviews regarding resident R141 |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 4, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident transfer/discharge notifications, bed hold policies, bed rail use, medication storage, and bed maintenance.
Findings
The facility failed to provide timely written transfer/discharge notices to residents and their representatives for emergent hospital transfers, did not permit a resident to return after therapeutic leave exceeding bed hold policy, failed to ensure informed consent and alternatives were documented for bed rail use, did not properly label and store medications including expired drugs, and failed to maintain and inspect bed frames and rails according to manufacturer's instructions.
Deficiencies (5)
Failed to provide timely written transfer/discharge notice to residents and their representatives for emergent hospital transfers.
Did not permit a resident to return to the nursing home after therapeutic leave exceeding bed hold policy.
Failed to ensure alternatives to bed rails were attempted, failed to document reasons for failure of alternatives, and failed to obtain informed consent for bed rail use.
Did not ensure medications were labeled and stored properly; expired medications were not removed from stock.
Failed to inspect and maintain bed frames and bed rails per manufacturer's instructions, lacking documentation of inspections.
Report Facts
Residents reviewed for transfer notice: 24
Residents affected by transfer notice deficiency: 6
Residents affected by bed rail deficiency: 2
Expired medications found: 9
Residents affected by bed maintenance deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BOM D | Business Office Manager | Involved in communication and decisions regarding resident R141's therapeutic leave and discharge |
| NHA-A | Nursing Home Administrator | Interviewed regarding transfer notice procedures and resident R141's discharge |
| DON | Director of Nursing | Interviewed regarding transfer notice procedures and bed rail use expectations |
| Maintenance Director | Interviewed regarding bed maintenance and inspection documentation | |
| RN-C | Registered Nurse | Interviewed regarding transfer paperwork given to residents |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care and catheter care for residents, specifically reviewing physician-ordered treatments and facility adherence to those orders.
Findings
The facility failed to ensure that physician-ordered treatments for pressure ulcers and catheter care were consistently provided due to lack of supplies, resulting in minimal harm or potential for harm to a few residents. Interviews revealed expectations for staff to follow orders and obtain alternate treatments if supplies were unavailable.
Deficiencies (2)
Failed to provide physician ordered pressure ulcer treatment for 1 resident (R11) due to lack of supplies.
Failed to provide physician ordered catheter care for 1 resident (R11) due to lack of supplies.
Report Facts
Residents affected: 1
Residents affected: 1
Medication administration chart code: 9
Physician order date: Aug 30, 2023
Physician order date: Sep 26, 2023
Irrigation volume: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN G | Registered Nurse | Documented acetic acid was out of stock on 10/08/2023 |
| RN T | Registered Nurse | Provided statements about supply storage and procedures for alternate orders |
| DON B | Director of Nursing | Discussed supply ordering and expectations for treatment per physician's order |
| NHA A | Nursing Home Administrator | Discussed supply ordering and expectations for following physician orders |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide residents with baseline care plans within 48 hours of admission and allowing uncertified staff to perform CNA duties.
Complaint Details
The complaint involved resident R2 not receiving a baseline care plan or summary after admission and concerns about uncertified staff performing CNA duties. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to provide resident R2 with a baseline care plan or summary within 48 hours of admission, and the comprehensive care plan lacked key information such as initial goals and physician's orders. Additionally, a Hospitality Aide (HA-H) was found to be performing CNA duties without proper certification, potentially affecting 7 to 10 residents.
Deficiencies (2)
Failure to create and provide a baseline care plan or summary to resident within 48 hours of admission.
Allowing a Hospitality Aide to perform CNA duties without proper certification.
Report Facts
Residents affected: 1
Residents affected: 7
Hours worked: 40
Hours worked: 80
Scheduled CNA exam date: Sep 13, 2023
Scheduled CNA shift hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HA-H | Hospitality Aide | Performed CNA duties without certification; scheduled to take CNA exam on September 13, 2023 |
| NHA-A | Nursing Home Administrator | Acknowledged facility error regarding uncertified CNA duties and discussed baseline care plan issues |
| DON-B | Director of Nursing | Discussed uncertified CNA duties and baseline care plan deficiencies |
| SSQD-C | Social Services Qualified Director | Interviewed regarding baseline care plan provision to resident |
| HR Manager-G | Human Resources Manager | Provided information on HA-H certification status and staffing |
| Scheduler-I | Scheduler | Confirmed HA-H work schedule and CNA hours counting |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Jan 17, 2023
Visit Reason
The inspection was conducted due to complaints and self-reports of resident-to-resident abuse incidents and concerns about medication management, dementia care, social services, pharmaceutical services, and medication storage.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident abuse involving residents R4, R11, R20, R26, and R85. The facility failed to report these incidents to law enforcement as required and did not fully investigate or implement effective interventions. Additional concerns included delayed psych services for a resident with dementia behaviors, inadequate social services follow-up, discrepancies in narcotic medication records, and improper medication storage.
Findings
The facility failed to timely report suspected abuse to law enforcement, did not fully investigate resident-to-resident abuse incidents or implement effective interventions, lacked timely psych services and updated care plans for a resident with dementia behaviors, did not provide adequate medically-related social services follow-up, had discrepancies in narcotic medication records for two residents, delayed pharmacist recommendations for medication changes, and failed to properly monitor medication refrigerator temperatures.
Deficiencies (10)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations including fully investigating resident-to-resident abuse incidents and implementing interventions to prevent further abuse.
Provide appropriate treatment and care according to orders, resident’s preferences and goals, including timely removal of unnecessary gastrostomy tube.
Provide appropriate pressure ulcer care and prevent new ulcers from developing by implementing pressure injury prevention measures per plan of care.
Provide safe and appropriate respiratory care for a resident when needed, including proper oxygen equipment maintenance and physician orders.
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia, including timely psych services and effective behavioral interventions.
Provide medically-related social services to help each resident achieve the highest possible quality of life, including psychosocial assessments and follow-up after behavioral changes or abuse incidents.
Provide pharmaceutical services to meet the needs of each resident and ensure accurate records of controlled substances and medication administration.
Ensure a licensed pharmacist perform a monthly drug regimen review and follow up on recommendations in a timely manner.
Ensure drugs and biologicals used in the facility are labeled and stored properly, including monitoring medication refrigerator temperatures daily.
Report Facts
Residents involved in abuse incidents: 5
Braden Scale scores: 14
BIMS scores: 4
BIMS scores: 12
Medication discrepancies: 2
Medication refrigerator temperature log missing days: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator-A | Administrator | Interviewed regarding failure to report abuse and psych services for R11. |
| Unit Manager-C | Unit Manager | Interviewed regarding incident reports, care plans, and medication storage. |
| Social Worker-J | Social Worker | Interviewed regarding psychosocial assessments and involvement in resident behavioral issues. |
| Director of Nursing-B | Director of Nursing | Interviewed regarding medication storage and psych services. |
| Registered Nurse-E | Registered Nurse | Interviewed regarding gastrostomy tube care for R67. |
| Medical Record Coordinator-F | Medical Record Coordinator | Interviewed regarding scheduling of gastrostomy tube removal appointment. |
| Nurse Practitioner-H | Nurse Practitioner | Interviewed regarding gastrostomy tube removal delay. |
| Nursing Home Administrator-A | Administrator | Interviewed regarding narcotic medication discrepancies. |
| CNA I | Certified Nursing Assistant | Interviewed regarding pain management for R82. |
| Unit Manager-D | Unit Manager | Interviewed regarding medication refrigerator temperature logs. |
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