Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aria Of Waukesha during CMS and state inspections, most recent first.
Failure to comprehensively assess and document a coccyx pressure injury on readmission. A resident with morbid obesity and DM was readmitted with a coccyx wound that was only measured and briefly staged by the RN, with no full wound characteristics or treatment documented at that time. A later wound consult identified the injury as a stage 3 pressure injury present on admission and ordered honey treatment, while the resident’s POC was not updated to reflect the new wound until weeks later.
The facility failed to accurately submit PBJ staffing data to CMS, resulting in low weekend staffing and missing RN hours being reported for multiple weekends. Survey review found the schedules and nurse postings did not match the PBJ report, and interviews confirmed that manual corrections were made but not resubmitted to CMS. The DON stated salaried nursing leadership covered some weekends, but those hours were not reported in PBJ.
Infection Control and Water Management Program Deficiencies: The facility lacked an effective WMP, with the IP not included on the team, no documented weekly temp or flushing logs, incomplete water system analysis, and no evidence the plan was included in the Facility Assessment. Surveyors also observed multiple second-floor rooms with shut-off or dry toilets, rust and calcium buildup, and blocked bathrooms. In addition, staff were observed entering rooms with droplet or droplet/contact precautions without appropriate PPE, and staff did not know which residents were on precautions or why.
A resident with respiratory failure, heart failure, muscle weakness, and significant mobility limitations was discharged home without a documented discharge summary, care conference notes, or verification that discharge goals were met. Although the care plan called for evaluating the resident’s ability to return to the community and therapy recommended home health services, there was no record that referrals were initiated, completed, or formally declined by the resident, who was cognitively intact. Discharge planning discussions and care conferences were not documented in the medical record, a paper discharge checklist was kept outside the record, and the facility relied on information from a family member without verifying it with the resident or documenting the availability and capability of caregivers or the safety of the discharge environment.
A resident with hemiplegia, epilepsy, and dependence for showering was care planned to receive assisted showers twice weekly and as needed, consistent with facility bathing policy. The resident reported no longer receiving regular Monday showers and believed her last shower had been about two weeks earlier, and later described a very brief shower that was essentially a quick rinse. Review of electronic POC records over the prior month showed multiple scheduled shower days marked as not applicable, one bed bath without explanation, one refusal, and several dates with no shower documentation at all, despite a census list indicating specific shower days. When the surveyor compared the POC records viewed onsite with a later printed copy, additional shower check marks appeared on dates that had not previously shown showers, and the facility did not provide a clear explanation for the missed showers or the altered documentation.
A resident’s room had mold on the ceiling tiles around the light, and surveyors observed the issue during an inspection. Maintenance staff said they had known about the problem for about a week but did not have replacement tiles, and the CIO stated the mold had been seen the day before and a work ticket would be entered.
A resident with DM received scheduled insulin three times daily, and BG checks were being obtained three times a day without documented BG parameters or hyperglycemia/hypoglycemia protocols in the physician order summary. The DON later confirmed the facility did not have BG orders with parameters for the resident and provided updated physician orders with BG parameters and interventions.
A resident returned from the hospital with an order for vancomycin prophylaxis, but the medication was temporarily out of stock at the pharmacy and three ordered doses were not administered. The MAR and notes showed the drug was on order, and staff interviews indicated the physician was not contacted at the time the medication was unavailable. The resident had ESRD, type 1 DM with CKD, and dialysis dependence, and was cognitively intact.
Pharmacy recommendations were not maintained in the chart or acted on promptly by the prescriber for two residents. One resident’s MMR noted a separate written report that could not initially be located in the medical record, and the recommendation was only provided after survey inquiry. Another resident, with CHF, dementia, and severe cognitive impairment, had repeated pharmacy review recommendations over several months that were not addressed until the NP later discontinued two PRN meds.
Insulin pens and vials on a medication cart were found open and used without being dated when opened, despite facility policy requiring a date-opened sticker and documentation of the open date and new expiration date. Surveyors observed multiple insulin products for several residents, including a Lispro pen, Lantus vial, Glargine pen, and Lispro vial, all labeled to discard after 28 days but lacking open dates; the RN, NHA, and DON were informed.
A resident with hemiplegia, hemiparesis, epilepsy, and bladder incontinence was observed waiting for assistance after activating her bedside call light for incontinence care. The light illuminated at the bedside but did not activate the indicator outside the room or at the nurse’s station, and the ADON stated she did not know why it was not working. A roommate’s call light had the same issue, and maintenance later found the outside light bulb was out.
A resident with cognitive impairment and a history of agitation was not properly assessed for elopement risk, resulting in the absence of necessary interventions such as a Wanderguard and targeted care planning. The facility's main entrance was left unmonitored and unalarmed during early morning hours, allowing the resident to leave unnoticed. The resident was found several hours later and miles away, highlighting failures in both assessment and supervision.
The facility failed to employ a qualified Dietary Manager or full-time nutritional professional, leading to inadequate menu planning and resident dissatisfaction with breakfast offerings. The DM, not certified, was responsible for menus and inventory, while the RD provided limited consultative work. Residents expressed concerns about the lack of meat in breakfast meals, which the DM was unaware of. The DON and Administrator confirmed the RD's consultant role and the DM's responsibility for menu planning.
The facility failed to maintain sanitary conditions in a resident refrigerator, leading to a buildup of ice and frost and the presence of unlabeled and undated food items. A resident reported the issue, and observations confirmed the unsanitary conditions. Interviews revealed a lack of clarity regarding responsibility for maintaining the refrigerator, with the DON and Administrator acknowledging the oversight.
A facility failed to ensure staff donned appropriate PPE for a resident on Enhanced Barrier Precautions. A nurse did not wear a gown while performing wound care, despite signage indicating the need for gowns and gloves. The resident had a stage IV pressure ulcer, an indwelling urinary catheter, and a feeding tube. The DON confirmed the expectation for staff to follow EBP, and the nurse attended training after the incident.
The facility did not follow its policies for conducting timely caregiver background checks, resulting in a Laundry Aide working before checks were completed and a CNA's checks not updated upon transfer. The HR Director and Regional Director confirmed the oversight, and the NHA acknowledged the failure to perform necessary checks.
Failure to comprehensively assess and document a coccyx pressure injury on readmission
Penalty
Summary
A resident readmitted to the facility with diagnoses including morbid obesity and diabetes mellitus had a coccyx pressure injury that was not comprehensively assessed on readmission. The medical record documented a stage 2 wound on the coccyx with only a measurement on the day of readmission, but there was no documentation of wound characteristics, drainage, odor, or treatment at that time. The resident’s hospital discharge summary did not document a coccyx wound or treatment orders for one. The next wound assessment was completed by an outside wound consultant several days later and identified the coccyx wound as a stage 3 pressure injury, present upon admission, measuring 6.3 cm by 4.6 cm by 0.1 cm with light sero-sanguinous drainage, slough, granulation tissue, and intact tissue. The treatment ordered at that time was Leptospermum honey daily and as needed. The treatment administration record showed coccyx treatment beginning after the readmission date, with no documentation of treatment being administered for several days after the resident returned to the facility. The resident’s plan of care for skin integrity was not revised to reflect the new pressure injury until weeks later. Prior to that revision, the resident had an existing skin plan focused on risk factors such as impaired mobility, diabetes, and malnutrition risk, but it did not address the newly identified coccyx pressure injury. Facility staff stated that the wound nurse handled comprehensive assessments and treatment orders, while the RN stated only measurements and rough staging were taken on readmission. The DON later stated the RN on the floor would be expected to complete a comprehensive wound assessment.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for Payroll Based Journal reporting for Fiscal Year Quarter 4 2025. Survey review of the PBJ Staffing Data Report showed excessively low weekend staffing, a one-star staffing rating, and no RN hours reported for multiple weekend dates in July, August, and September 2025. The deficiency involved the accuracy of staffing data submitted from payroll and other verifiable auditable records. During the survey, the DON provided an email from the Corporate Director of Recruitment stating that information had been entered incorrectly into the PBJ staffing report, which resulted in inappropriate staffing levels being reported. The email also stated that manual updates had been made by the facility for days missing RN hours, but the resubmission step to CMS was not completed. The surveyor reviewed facility weekend schedules, nurse postings, and staffing ratios and found no discrepancies between the schedules and the RN hours during the quarter. Interviews with the DoR and DON confirmed that the facility had identified missing or inaccurate RN hours and had made manual corrections, but the corrected hours were not resubmitted to CMS. The DON stated that salaried nursing leadership covered some weekends when no RN was scheduled, but those hours were not reported in PBJ because salaried staff are not paid hourly. The NHA was informed of the concern that the staffing hours were not accurately reported for the quarter.
Infection Control and Water Management Program Deficiencies
Penalty
Summary
The facility did not maintain an infection prevention and control program with an effective water management plan. Survey review found the water management program manual identified a team of the DON, maintenance director, and NHA, but the infection preventionist was not included as a team member. The manual included a water flow diagram, but it did not identify points where Legionella or other waterborne pathogens could grow, did not include a risk assessment of the water system, did not describe control measures and monitoring, and was not included in the Facility Assessment. The facility also could not provide documentation of weekly temperature testing or weekly flushing logs for vacant second-floor rooms or for rooms tested on the first floor. Surveyors observed conditions on the closed second floor that were consistent with rooms not being actively maintained in the water management program. In the emergency eye washing station room, tape across the toilet seat stated no water and do not use, with a small amount of water and rust staining in the bowl and an open shower with calcium buildup around the drain and no shower head. In other rooms and connecting bathrooms, surveyors noted toilets with water and rust stains, toilets marked do not use with the water shut off, dry toilet bowls with rust stains, and sinks with calcium deposits and rust stains. Bathrooms in several rooms were blocked by walkers, wheelchairs, and other equipment, and surveyors could not enter those bathrooms. During interview, Maintenance-D stated the facility did not keep logs and that he just knew what had been flushed and tested. He stated the second floor sinks were turned on for 2 to 3 minutes and toilets were flushed 2 to 3 times biweekly, and that first-floor bedrooms were flushed if a resident was not in the room. Maintenance-D and the NHA were not sure how long the second-floor units had been shut down, and Maintenance-D stated there had not been a water management team meeting to review the plan or parameters for water temperatures or what to do if a control measure was out of range. The NHA stated the previous maintenance director threw away all logs, and Maintenance-D was unable to walk the surveyor through the water flow diagram or identify areas where Legionella or other waterborne pathogens could grow. The facility also had observations of staff not wearing appropriate PPE in rooms with droplet precautions signs posted. Surveyors observed a sign outside one resident's room stating droplet precautions, but there was no PPE cart outside or inside the room. A hospice aide and a CNA were observed in the room without appropriate PPE while handling laundry, garbage, and other tasks, and neither staff member knew which resident was on precautions or why. The sign was later removed. In another room with special droplet/contact precautions, a PPE cart was present, but multiple staff members were observed inside the room without PPE other than one staff member wearing only a surgical mask. Staff outside the room told a visitor they did not know whether one of the residents had COVID, and the precaution sign was later changed to enhanced barrier precautions. Review of the medical record showed one resident in the first room had no evidence of COVID or respiratory infection, while the roommate had a positive rapid COVID test, and another resident in the second room had a positive rapid COVID test.
Failure to Document and Coordinate Safe Discharge Planning and Home Health Referrals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that discharge planning for one cognitively intact resident included documented coordination of services, resident participation, and verification of a safe and appropriate transition to the community. The facility’s own Discharge Planning policy requires timely documentation of discharge needs and plans, discussion of the evaluation results with the resident or representative, and development of a post-discharge plan of care indicating the discharge location and arrangements for follow-up care and services. For this resident, the medical record did not contain a completed discharge summary, documentation of a care conference discharge meeting, or confirmation that post-discharge needs and services were fully addressed prior to discharge. The only progress note related to discharge indicated that the resident was discharged home with paperwork and medications, that van transport arrived, and that a family member was waiting at the destination. The resident was admitted with respiratory failure, cognitive communication deficit, heart failure, and muscle weakness, and had significant functional limitations requiring substantial/maximal assistance with transfers and dependence for walking at admission. At discharge, the MDS showed the resident remained cognitively intact with a BIMS score of 13, required partial/moderate assistance for sit-to-stand and bed-to-chair transfers, and was not assessed for car transfer or walking 10 feet due to medical or safety concerns. The care plan documented that the resident wished to discharge home or to the community, with interventions to evaluate the resident’s motivation and ability to safely return to the community and to identify gaps in abilities affecting discharge. However, there was no documentation that these evaluations and care plan interventions were completed or that discharge goals were met before the resident left the facility. Interviews with staff revealed that the social worker managed discharge planning and home health referrals but did not document care conferences or discharge planning discussions in the medical record, instead keeping and then deleting personal notes. The LPN reported that nursing’s role in discharge was limited to belongings and medication management, that a paper discharge checklist was used but not part of the medical record, and that the discharge was “fast and abrupt” once insurance ended. The OT stated that therapy determined the resident was not appropriate to live alone at discharge, recommended home health services, and communicated these recommendations to the social worker, but the medical record contained no documentation that home health referrals were initiated, completed, or formally declined by the resident. The social worker reported that a phone conversation with the resident’s brother led to not sending the home health referral, based on the brother’s reluctance to have services in the home and his statement that family would assist, but this was not documented, and the facility did not verify this information with the resident, who was his own decision maker. There was no documentation confirming the adequacy of caregiver support or the safety of the discharge environment, and leadership acknowledged that the expected discharge summary, care conference documentation, and follow-through on therapy referrals were not present in the record.
Failure to Provide and Accurately Document Scheduled Showers for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a dependent resident received necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, as outlined in facility policy and the resident’s care plan. The resident, admitted with hemiplegia and hemiparesis following a cerebral infarction, epilepsy, and neuralgia/neuritis, had a BIMS score of 14 indicating no cognitive impairment but was documented as dependent for showering/bathing in the MDS. The resident’s care plan and Kardex required assistance from two staff for bathing/showering twice weekly and as needed. Facility policy required that all residents be offered a bath or shower at least weekly or per preference, and that refusals be reported to a nurse and documented by a licensed nurse. During an interview, the resident reported needing help with ADLs and stated that she previously received a shower every Monday but no longer did, estimating her last shower was about two weeks prior. She also expressed a preference for showers before 10:00 AM. On the same day, the surveyor found the resident’s call light not working for at least an hour while the resident was crying, needed changing, and requested ice water. Later that morning, staff were observed wheeling the resident back from a shower; afterward, the resident reported that the shower lasted about two minutes and that she was only rinsed with water. Review of the Point of Care (POC) bathing/shower documentation for the prior 30 days showed multiple dates on which the resident’s scheduled shower days were marked as “not applicable,” with no documentation that a shower occurred, and one date with a bed bath documented without explanation for why a shower was not provided. One date showed a refusal, but other scheduled shower days had no documentation of a shower or refusal. When the surveyor later compared printed POC shower documentation to what had been viewed onsite, there were discrepancies, including added check marks under “shower” on dates that had not previously shown showers. The facility did not provide documentation that the resident consistently received showers as care planned on all scheduled days, nor an explanation for the discrepancies in shower documentation or for the missed showers for a resident unable to perform ADLs independently.
Mold Observed in Resident Room Ceiling
Penalty
Summary
The facility did not ensure that one resident had a clean, comfortable, and homelike environment when mold was observed on the ceiling tiles around the light in the resident’s room. The facility’s housekeeping policy states that housekeeping and maintenance services are required to maintain a sanitary, orderly, and comfortable interior. Survey observation on 02/09/2026 found mold on the ceiling in the resident’s room, and the resident stated the facility was aware of the issue and said it would be fixed. On 02/10/2026, maintenance staff reported they had been aware of the issue for about one week but did not have replacement tiles and would need to buy new ones, and the Chief Innovation Officer stated the mold had been seen the day before and that a work ticket would be put in and addressed immediately.
Missing Blood Glucose Parameters for Resident Receiving Scheduled Insulin
Penalty
Summary
The facility did not ensure that treatment and care were provided according to orders, resident preferences, and goals for 1 of 5 residents reviewed. The resident had diabetes mellitus and received scheduled insulin three times a day. The physician order documented insulin lispro 5 units subcutaneously three times a day and not to give it if the resident did not eat. The MAR showed that blood sugars were obtained three times a day while the resident received scheduled insulin, but the physician order summary did not include blood glucose orders with parameters or any hyperglycemia or hypoglycemia protocols for blood sugar variances. During surveyor interview, the DON stated the facility did not have blood glucose orders with parameters for the resident and later provided physician blood sugar orders with parameters dated 2/10/26 that included interventions for hypoglycemia and hyperglycemia.
Missed antibiotic doses after hospital return
Penalty
Summary
The facility did not ensure accurate and safe medication administration for one resident, R5, when a physician-ordered antibiotic was not available for administration as ordered. R5 returned from the hospital on 12/16/25 with an order for Vancomycin HCl Oral Suspension 50 MG/ML, 2.5 ml by mouth every morning and at bedtime for 14 days for C. diff prophylaxis. R5’s record showed a bedtime dose was not given on 12/16/25, and both the morning and bedtime doses were not given on 12/17/25, for a total of three missed doses. R5 was admitted with diagnoses including end stage renal disease, type 1 diabetes mellitus with diabetic chronic kidney disease, and dependence on renal dialysis. The MDS documented a BIMS score of 13, indicating R5 was cognitively intact, and also documented that an antibiotic was given. The MAR and progress notes showed the medication was on order, and a note on 12/17/25 stated the vancomycin was temporarily out of stock at the pharmacy and would be sent when available, with no ETA provided. During interview, the LPN stated the medication was temporarily out of stock at the pharmacy and was sent when available, and the LPN did not see documentation that the physician was contacted. The DON later obtained documentation from the NP stating the NP was made aware the medication was not available and did not wish to extend the vancomycin course because it was prophylactic and the resident had no signs or symptoms of C. diff. The surveyor noted there was still no evidence that the ordered doses were given as prescribed, and the resident missed three doses of vancomycin.
Pharmacy recommendations not maintained in record or acted on promptly
Penalty
Summary
The facility did not ensure that licensed pharmacist medication regimen review recommendations were maintained in the medical record and acted upon promptly by the primary care provider, as required by its policy for Consultant Pharmacist Reports. The policy states that recommendations are to be acted upon and documented by facility staff and/or the prescriber, and that the prescriber accepts and acts upon the suggestion or rejects it with an explanation. This deficiency was identified in 2 of 5 resident pharmacy record reviews, involving R10 and R42. For R10, a pharmacist completed an MMR on 12/6/25 and documented that recommendations were in a separate written report, but the report was not found in the medical record when first reviewed. The DON and NHA stated the report could not be located and had not been sent, while the pharmacist stated reports were sent electronically. The written recommendation was later provided on 2/11/26 after survey inquiry, and it had not been acted upon promptly by the medical provider. For R42, who had chronic diastolic CHF, cognitive communication deficit, dementia with anxiety, hallucinations, and a BIMS score of 03 indicating severe cognitive impairment, pharmacy review notes from multiple months documented repeated recommendations to the facility. The DON stated the same recommendation had been made on each of those dates, but the nurse practitioner did not sign off to discontinue the two PRN medications until 2/9/26, and prior pharmacy recommendations had not been addressed promptly.
Insulin Pens and Vials Not Dated When Opened
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles because insulin pens and vials on the west unit medication cart were not dated when opened. The facility policy titled Storage of Medications states that when the original seal of a manufacturer's container or vial is broken, the container or vial will be dated, and the nurse shall place a date-opened sticker on the medication and enter the date opened and the new expiration date. However, the bottom drawer of the medication cart contained a plastic bin with resident insulin pens and vials that lacked open dates. During observation on the west unit medication cart, surveyors found a Lispro insulin Kwik pen for R4, a Lantus vial for R26, a Glargine insulin pen for R39, and a Lispro insulin vial for R39, all open and used but not dated when opened. The labels on these insulin products documented to discard after 28 days. The RN was informed of the findings, and later the NHA and DON were advised of the same observations. The DON stated that pharmacy had just completed an audit about two weeks earlier.
Nonfunctioning bedside call system
Penalty
Summary
The facility did not ensure a working call system was available from a resident’s bedside, as R23’s call light illuminated on the wall next to the bed but did not activate the light outside the room or the call board at the nurse’s station. R23 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, focal epilepsy with complex partial seizures, and neuralgia and neuritis. Her MDS documented a BIMS score of 14, indicating no cognitive impairment. Her care plan identified bladder incontinence, dependence for toileting, and the need to encourage use of a bell to call for assistance. During observation, R23 was lying in bed and reported she needed to be changed for incontinence; she stated her call light had been on for about 45 minutes and became tearful while trying to reposition herself. Surveyor observation and interview confirmed the bedside call light remained illuminated inside the room while the light above the door stayed off, and the nurse’s station board showed the room as needing attention. The ADON observed the issue and stated she did not know why the outside light was not on. When the roommate tested her own call light, it also lit up at the bedside but not outside the room. Maintenance later identified the problem as a bulb that was out. During the period the call system was not functioning outside the room, R23 remained waiting for assistance with incontinence care and requested ice water while the surveyor was present.
Failure to Prevent Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and accident prevention for a resident with cognitive impairment and a history of agitation and confusion. Upon admission, the resident had diagnoses including encephalopathy, vascular dementia, and mood disturbances, and had demonstrated agitation and a desire to leave home prior to admission. Despite this, the facility's elopement risk assessment was completed incorrectly, omitting points for mobility status and being new to the facility, resulting in the resident not being identified as at risk for elopement. Consequently, the resident was not provided with a Wanderguard or specific interventions to prevent elopement, and the care plan did not address elopement risk or the resident's ongoing expressions of wanting to leave. The facility's monitoring procedures were insufficient, particularly at the main entrance. The front doors were unlocked during early morning hours before the reception area was staffed, and there was no alarm or staff presence to monitor residents exiting the building during this time. The resident was last seen in the early morning, and staff did not notice the absence until an hour later, at which point a search was initiated. The lack of supervision and monitoring allowed the resident to leave the facility unnoticed. The resident was found eight hours later, twenty miles away from the facility, after a Silver Alert was issued and family members assisted in the search. The resident sustained superficial abrasions and required evaluation in the emergency department. Interviews with staff confirmed gaps in the elopement risk assessment process, care planning, and entrance monitoring, all of which contributed to the resident's ability to elope from the facility without detection.
Removal Plan
- All facility residents were re-assessed to identify risk for elopement and ensure proper interventions were implemented.
- Identified residents at risk for elopement and ensure person centered care plans are in place with preventative measures to include the specified level of supervision for residents at risk for elopement.
- Reviewed elopement/missing resident policy to address the timing of searching for/reporting a missing resident to help ensure an expedited search.
- Education was provided to all staff on following the facility's updated elopement policy, accuracy of elopement assessments, monitoring resident's at risk for elopement and timely response to door alarms.
- Elopement risk assessments completed will be reviewed during clinical meeting to verify accuracy and ensure appropriate interventions were put in place.
- New elopement risk assessments were completed for all facility residents.
- Facility implemented cameras at facility entrance.
- Reviewed updated facility policy and procedure on elopement and coordination with medical director. Including updated elopement assessments, and addition of cameras at the facility entrance to ensure adequate resident supervision is in place to identify residents exiting the facility and to ensure facility policy and procedure meets current standard of practice.
- Facility Maintenance will complete audits to ensure door alarms are properly functioning. Audits will be completed on all shifts.
- IDT will review in clinical meeting any new admissions elopement assessments, incidents regarding changes in residents' behaviors, and document on eagle board to ensure proper assessments have been obtained and appropriate interventions have been implemented. Audits will be conducted. Results will be reviewed by QAPI Committee to determine compliance or additional follow up required.
- An Ad Hoc QAPI completed.
Deficiency in Dietary Management and Menu Planning
Penalty
Summary
The facility failed to employ a qualified Dietary Manager (DM) or a clinically qualified nutritional professional on a full-time basis to oversee the menus, leading to concerns about kitchen management and menu planning. The DM, who has been in the role for about two years, confirmed she was not a Certified Dietary Manager and believed the facility had a full-time registered dietitian (RD). However, the RD was only a consultant providing three to four hours of remote consultative work per week. The DM was responsible for the menus, ordering, and maintaining inventory, while the RD was responsible for resident assessments. This lack of full-time qualified personnel resulted in inadequate menu planning, as evidenced by the repetitive breakfast menu lacking meat protein, which was a concern expressed by residents. Residents R25, R9, R11, and R49 expressed dissatisfaction with the breakfast menu, noting the absence of meat. During interviews, the DM was unaware of these complaints and stated that the RD was responsible for creating menus that met residents' nutritional needs. The facility's Director of Nursing (DON) and Administrator confirmed the RD was a consultant and that the DM was responsible for menu planning with the help of an automated program. They were unaware of the residents' dissatisfaction with the breakfast offerings. This situation highlights the deficiency in employing qualified staff to ensure the nutritional needs and preferences of residents are met.
Failure to Maintain Sanitary Conditions in Resident Refrigerator
Penalty
Summary
The facility failed to maintain sanitary conditions in the East unit refrigerator, which was designated for resident use. During an interview, a resident reported that the refrigerator was unclean and required defrosting. Observations confirmed a significant buildup of ice and frost in the freezer section, along with unlabeled and undated items such as plastic soda bottles, leftover fast-food containers, and opened condiment containers. These conditions were contrary to the posted instructions on the refrigerator door, which required all items to be labeled, dated, and discarded after three days. Interviews with facility staff revealed a lack of clarity regarding responsibility for maintaining the cleanliness and organization of the refrigerator. The Director of Nursing (DON) indicated that dietary staff were responsible for cleaning, while nursing staff were tasked with labeling and dating items. However, the Administrator acknowledged that the facility had not assigned specific responsibility for cleaning the resident refrigerators, leading to the oversight. The facility's infection control policy emphasized the importance of maintaining a safe and sanitary environment to prevent infection, but this was not adhered to in the case of the East unit refrigerator.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff donned the appropriate personal protective equipment (PPE) when providing direct care to a resident on Enhanced Barrier Precautions (EBP). Specifically, a registered nurse (RN) did not wear a gown while performing wound care on a resident with a stage IV sacral pressure ulcer, an indwelling urinary catheter, and a feeding tube. The resident's room had signage indicating the need for EBP, which includes wearing gowns and gloves during high-contact care activities. Despite this, the RN only wore gloves and was unaware that the resident was on EBP. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene and wear gowns and gloves when providing direct care to residents on EBP. The DON also stated that staff had recently been instructed on EBP precautions. However, the RN involved in the incident had attended a training session on EBP after the deficiency was observed, indicating a lapse in adherence to the facility's infection prevention and control program.
Failure to Conduct Timely Background Checks for Staff
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse by not ensuring thorough and timely caregiver background checks for two staff members, a Laundry Aide and a Certified Nursing Assistant. The facility's Abuse Prevention Program mandates pre-employment screening, including obtaining a Wisconsin Criminal History Record and a caregiver background check before a new employee starts work. However, the Laundry Aide began working before these checks were completed, and the Certified Nursing Assistant's background checks were not updated upon transferring from a sister facility. The Human Resources Director and Regional Director of Clinical Operations confirmed that background checks should be completed before an employee's first shift and when transferring between facilities. Despite this, the Laundry Aide worked several shifts before the background checks were conducted, and there was no evidence of a national criminal background check for the Laundry Aide, who had previously resided in Florida. The Nursing Home Administrator acknowledged the oversight, confirming that the necessary checks were not performed as required by the facility's policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waukesha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Kensington | 2.5 mi | ★★★★★ | 5 | 0 |
| Avina Of Pewaukee | 2.7 mi | ★★★★★ | 5 | 0 |
| Lindengrove Waukesha | 2.7 mi | ★★★★★ | 20 | 1 |
| Complete Care At Care Age | 3.4 mi | ★★★★★ | 1 | 0 |
| Aria Of Brookfield | 3.9 mi | ★★★★★ | 39 | 0 |
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