Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Menomonee Falls Health Services during CMS and state inspections, most recent first.
A resident with multiple diagnoses and a documented intact cognitive status was left with a cup containing six medication pills on the overbed table while sleeping, without a completed self-administration assessment or authorization. An LPN confirmed leaving the medications at the bedside, and the resident later self-administered them after returning from therapy. The DON acknowledged that medications should not be left at the bedside without proper assessment.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care. One resident developed a stage 3 ischium pressure injury, with delayed implementation of treatment orders and inconsistent use of heel boots. Another resident had a DTI inaccurately staged as a Stage I injury, with delayed treatment and inconsistent documentation. The facility failed to adhere to its pressure injury policy, impacting care quality.
A facility failed to notify a resident's HCPOA of new open areas on the resident's foot and ankle, as required by policy. The resident, with severe cognitive impairment, was not properly communicated about their wound status, and documentation in the EMR was incomplete until the survey process began. The DON acknowledged the expectation for immediate notification, but the facility's wound tracker lacked necessary details.
A resident in an LTC facility was not provided care according to their comprehensive care plan and physician orders. The resident, with a history of severe malnutrition and dementia, was observed without prescribed tubigrips and heel boots, essential for preventing pressure injuries. The care plan was not updated with new interventions after identifying an arterial wound, and staff interviews revealed a lack of adherence to the care plan. The DON acknowledged a disconnect in processing treatment orders, leading to a deficiency in care.
A resident with hearing and vision impairments did not receive necessary treatment and assistive devices, as observed during a survey. The resident was frequently seen without glasses or hearing aids, which were documented as needed in their care plan. The facility's staff were either unaware of the requirements or unable to ensure the use of these devices. The resident's hearing aids were reportedly lost, and there was no documentation of efforts to replace them or arrange for an audiology consultation.
Two residents in the facility had incomplete medication administration records over several months, with numerous medications not documented as administered. Despite the facility's policy requiring immediate documentation, staff interviews revealed delays due to a busy environment. The Director of Nursing confirmed the expectation for immediate documentation but did not explain the deficiencies.
Two residents developed stage 3 pressure injuries due to inadequate care and prevention measures. One resident, with multiple health conditions and incontinence, did not receive a comprehensive assessment or updated care plan, leading to a sacral pressure injury. Another resident's coccyx injury was incorrectly staged, delaying treatment. The facility failed to personalize care plans and implement effective pressure injury prevention policies.
A facility failed to provide adequate supervision and assistance devices, resulting in multiple falls and injuries for two residents. One resident experienced several falls due to inadequate investigation and care plan revisions, leading to a hip fracture. Another resident, assessed as requiring supervision while smoking, was found smoking alone, contrary to the facility's policy. The facility's lack of thorough investigations and consistent application of safety interventions highlighted deficiencies in accident prevention and resident supervision.
The facility failed to provide sufficient nursing staff, particularly during night shifts, leading to delayed call light responses and resident concerns. Despite using a scheduling program, the facility was consistently short-staffed, with discrepancies in staffing records. Residents reported long wait times for assistance, especially after medical procedures, and had not been informed of any resolutions to their concerns.
The facility failed to adhere to professional standards for food storage and safety, affecting all 30 residents. A surveyor observed a jug of barbeque sauce on the floor, an unlabeled bag of white powder, and undated food items in the kitchen. The dietary manager admitted the sauce was used to prop open a door, violating policy. The nursing home administrator was informed, but no further details were provided.
The facility failed to properly dispose of garbage and refuse in the outside storage area, leading to an accumulation of debris, including wood pallets, a refrigerator, and garbage bags mixed with pine needles and pinecones. The Dietary Manager and Maintenance Director were unclear about their responsibilities, resulting in inadequate maintenance of the area.
The facility failed to maintain consistent staffing on weekends, as revealed by the PBJ data for the first quarter of fiscal year 2023, which showed excessively low weekend staffing. The facility's assessment required specific staffing levels based on resident census and acuity, but discrepancies were found, particularly on weekends. The DON used Smart Linx for scheduling, but the facility was still flagged for low staffing. The Regional VP identified a systemic issue with agency staff hours not being accurately reported, affecting weekend staffing data.
The facility failed to maintain an effective infection control program, with missing data in infection logs, unreviewed policies, and inadequate water management practices. A resident with C-Diff was not logged, and staff did not follow proper hygiene protocols, such as handwashing and medication handling. Additionally, the water management plan lacked documentation and involvement from the DON, leading to potential risks of Legionella spread.
The facility failed to provide a safe, clean, and comfortable homelike environment, affecting residents in the dining room and two residents observed for care. Meals were served on trays, and strong urine odors and yellow stains were noted in residents' rooms.
The facility failed to document code status for several residents, with missing or unsigned DNR forms and lack of evidence of discussions confirming residents' wishes. The process relied on verbal confirmation and electronic entries without formal documentation.
The facility failed to address pharmacy recommendations for several residents, leading to deficiencies in medication management. Recommendations for dosage specifications, medication discontinuation, and assessments were repeatedly ignored, affecting residents with conditions such as rheumatoid arthritis, anxiety, and epilepsy. The lack of follow-up on these recommendations highlights systemic issues in the facility's medication management processes.
A resident was not provided with the necessary Advanced Beneficiary Notice (ABN) or Notice of Medicare Non-Coverage (NOMNC) when their Medicare Part A benefits ended. The facility's regional vice president confirmed the absence of these documents, and the social services coordinator, new to the role, was unable to locate them. The nursing home administrator was informed of the issue.
The facility failed to provide required written transfer notices to residents and their representatives during hospitalizations, lacking details such as appeal rights and ombudsman contact information. Staff interviews revealed confusion about the responsibility for issuing these notices, and the provided forms were missing necessary regulatory information.
The facility failed to notify residents and their representatives of the bed-hold policy during hospital transfers, affecting three residents who were hospitalized. Despite the facility's policy requiring notification within 24 hours of transfer, no such notices were provided. Interviews with staff revealed confusion about responsibility for this task, and documentation was lacking for all affected residents.
A resident diagnosed with a psychotic disorder did not have an updated PASARR level 1 screen or a level 2 referral, despite the new mental health diagnosis. The facility's records lacked evidence of the necessary updates, and the social service staff confirmed that while a new level 1 screen was completed, a level 2 screen had not yet been done.
A resident with multiple medical conditions, including bilateral amputation and chronic heart failure, did not receive scheduled showers at a facility. Despite being scheduled for showers twice weekly, documentation and interviews revealed inconsistencies and a lack of clear policy, resulting in the resident not receiving necessary grooming services.
The facility failed to provide adequate wound care and treatment documentation for three residents. A resident with lymphedema and diuretic use lacked a comprehensive care plan and monitoring for adverse reactions. Another resident with a neoplasm was not properly assessed, and staff did not verify or assist with treatment. A third resident with a venous stasis ulcer did not receive treatments as ordered, and the wound was not properly cleaned or documented. These deficiencies highlight a lack of adherence to professional standards of practice in wound care.
A resident readmitted with a Foley catheter was not assessed for removal, and the facility failed to follow up on a urology referral. The resident's care plan lacked documentation of the catheter, and there was inconsistent recording of urinary continence status. The facility's policy did not address catheter removal assessment.
Two residents experienced significant weight changes without proper monitoring or intervention. One resident lost 48 pounds over three months, with no re-weighs or notifications to the dietician or physician. Another resident had a physician's order for weekly weights, but several weeks' weights were not documented. The facility failed to adhere to its weight monitoring policy, leading to deficiencies in nutritional care.
A facility failed to conduct a trauma-informed care assessment for a resident with PTSD, anxiety, and depression, resulting in a non-individualized care plan. The resident confirmed that no one had asked about her PTSD triggers, and the social worker was unaware of the requirement for trauma assessments. The CNA Kardex lacked specific interventions for the resident's PTSD, leading to a deficiency noted by the surveyor.
The facility failed to monitor heart rates for two residents before administering Metoprolol, as required by physician orders, and administered an unnecessary antibiotic to another resident without adequate signs of a UTI. The antibiotic was continued at the request of a family member, despite the resident not meeting infection criteria.
A facility was found to have a medication error rate of 21.05%, significantly above the acceptable threshold. Errors included improper crushing of extended-release medication, holding medication without physician orders, and failure to administer multiple prescribed medications to residents. The facility's documentation did not show that physicians were notified of these omissions, indicating non-compliance with medication administration policies.
The facility failed to properly label insulin pens, as observed in the Deerpath medication cart. Several insulin pens were found open and used without being dated when opened, and one pen lacked a proper resident label. These issues were noted by a surveyor and reported to the RN and DON, but no further information was provided.
A Life Enrichment Specialist, not certified as a CNA, was observed feeding a resident with multiple diagnoses, including chronic kidney disease and diabetes, without completing a state-approved training course. The facility's DON confirmed the absence of paid feeding assistants and the LES's lack of certification. Despite a detailed care plan requiring assistance with eating, the LES fed the resident breakfast on two occasions, leading to a deficiency finding.
The facility did not have a hospice policy and procedure, affecting the coordination of care for residents receiving hospice services. This deficiency was identified when surveyors found no hospice contract or policy in the facility's records, and the DON confirmed its absence. Two residents receiving hospice care were impacted, with one having severe malnutrition and the other with chronic kidney disease and other conditions. The facility's hospice care plans lacked specificity, and there was no designated IDT member for coordinating care with hospice services.
The facility failed to document influenza and pneumococcal immunizations for three residents, as required by their policies. Medical records lacked documentation of whether the residents received or refused these vaccines, which was only confirmed through the Wisconsin Immunization Registry after surveyor inquiry. The Director of Nursing oversees the immunization program, but the process was not effectively documented, leading to the deficiency.
Two residents were found self-administering medications without proper assessments or physician orders. One resident, with multiple health conditions, had medications on her over-bed table without a self-medication assessment. Another resident, with a history of cancer and other diagnoses, was performing his own wound treatment without oversight, while nursing staff inaccurately documented treatment administration. The facility failed to follow its policy requiring assessments and orders for self-administration.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a resident was not assessed for clinical appropriateness to self-administer medications, yet was left with a cup containing six medication pills on the overbed table while sleeping. The resident's medical record did not include a completed self-administration assessment, and the quarterly MDS indicated the resident was cognitively intact. Despite this, the facility's policy requires specific authorization and assessment before allowing self-administration of medications. The LPN confirmed leaving the medications at the bedside while the resident was asleep, and the resident later confirmed self-administering the medications after returning from therapy, expressing surprise at finding the medications left out. Observations showed the medication cup remained on the overbed table for several hours, even when the resident was not present in the room. The MAR indicated the medications were documented as administered at the scheduled time, although the resident did not take them until much later. The DON confirmed that medications should not be left at the bedside without proper assessment and authorization. No explanation was provided for the failure to ensure the resident was clinically appropriate for self-administration of medications.
Deficiencies in Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for two residents, R5 and R7, leading to deficiencies in pressure ulcer care. R5, who was at risk for pressure injuries, developed a stage 3 ischium pressure injury. Despite recommendations from the wound doctor to upgrade the offloading chair cushion and initiate specific treatment orders, these were not implemented until several days later. Observations revealed that R5 was not repositioned every two hours as required, and heel boots were not consistently worn, contrary to the care plan. R7 was admitted with a Deep Tissue Injury (DTI) to the left heel, which was inaccurately staged as a Stage I pressure injury by RN-D. The treatment for the left heel was delayed by two days post-admission, and there was a lack of documented assessments after a certain date, despite the presence of a dark area on the heel. The facility's documentation was inconsistent, with conflicting reports about the staging and healing status of the pressure injury. The facility's policy on pressure injuries was not adhered to, as evidenced by the lack of timely updates to care plans and the failure to implement recommended interventions. The Director of Nursing acknowledged the oversight in processing treatment orders and the absence of a root cause analysis for the development of new pressure injuries. These deficiencies highlight a breakdown in communication and documentation processes within the facility, impacting the quality of care provided to residents.
Failure to Notify HCPOA of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the health care power of attorney (HCPOA) for a resident when there was a change in condition and a need to alter treatment. Specifically, the HCPOA was not informed when the resident developed open areas below the left pinky toe and on the left outer ankle on November 5, 2024. The facility's policy requires informing residents or their responsible parties about the presence and status of wounds, but this was not adhered to in this case. The Director of Nursing (DON) acknowledged that there was no specific facility policy for notification, and the expectation was that the representative should be notified immediately. The resident in question had a history of severe cognitive impairment, requiring total assistance with activities of daily living, and was dependent on staff for mobility and personal care. The resident's HCPOA was only informed of the wound status by the wound doctor, not by the facility staff. The facility's wound tracker documentation was incomplete, with missing information on who was notified and when. The surveyor's review of the electronic medical record (EMR) confirmed that the notification section was blank until the survey process began, indicating a lapse in communication and documentation by the facility staff.
Failure to Adhere to Resident's Care Plan and Physician Orders
Penalty
Summary
The facility staff failed to provide care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident, identified as R5. R5 was observed not wearing the prescribed size D double tubigrips on their bilateral lower extremities, which were ordered to be worn 23 hours a day as tolerated. Additionally, R5 was not wearing the physician-ordered off-loading bilateral heel boots during the survey process. These observations were made despite the resident's care plan and physician orders clearly documenting the necessity of these interventions to prevent pressure injuries and promote healing. R5, who has a history of severe protein-calorie malnutrition, dementia, and other comorbidities, was admitted to the facility with existing pressure injuries and was at risk for developing further pressure injuries. The resident's care plan was not updated with new interventions following the identification of an arterial open area on R5's right first toe. The care plan was only revised on the first day of the survey process, and no new interventions were implemented at the time of identification. Furthermore, the facility's Director of Nursing acknowledged that the treatment orders from a wound doctor were not processed in a timely manner, contributing to the lack of appropriate care. Throughout the survey process, R5 was observed multiple times without the necessary tubigrips and heel boots, and there was no evidence of repositioning every two hours as required. Interviews with facility staff, including a CNA and an LPN, revealed a lack of awareness and adherence to the resident's care plan. The Director of Nursing admitted to a disconnect in processing treatment orders and acknowledged that the care plan should have been updated with new interventions when the open areas were first identified. This failure to ensure that R5 received the necessary treatment and services consistent with professional standards of practice resulted in a deficiency in the care provided to the resident.
Failure to Provide Necessary Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that a resident with hearing and vision impairments received the necessary treatment and assistive devices. The resident, who has diagnoses including dementia, sensorineural hearing loss, and severe protein-calorie malnutrition, was observed multiple times without wearing glasses or hearing aids. The resident's care plan and Kardex indicated the need for these devices, yet they were not consistently used or available. The resident's hearing aids were reportedly lost, and there was no documentation of efforts to replace them or arrange for an audiology consultation. The facility's policy on the use of assistive devices requires that such devices be provided based on a comprehensive assessment and in accordance with the resident's care plan. However, the staff, including a CNA and an LPN, were either unaware of the resident's need for hearing aids or unable to ensure their use. The Director of Nursing acknowledged the loss of the hearing aids and the need for a care plan update but did not provide evidence of actions taken to address the issue. The resident's medical records showed a lack of follow-up on a physician's order for an audiology consultation, which had not been completed since March 2024. Observations during the survey revealed that the resident's glasses were often not within reach, and the resident was not wearing them during meals or while watching television. The facility did not provide additional information to explain why the necessary treatment and services were not provided to promote the resident's quality of life.
Incomplete Medication Administration Records for Two Residents
Penalty
Summary
The facility failed to ensure that medication administration records (MARs) were complete and accurate for two residents, R1 and R3, over a period from September 2024 to November 2024. The MARs for both residents contained numerous empty signature boxes, indicating that medications were not documented as administered by the nursing professionals responsible for their care. This lack of documentation was in direct violation of the facility's policy, which mandates that the individual administering the medication must record the administration immediately after the medication is given. R1, who was admitted with multiple diagnoses including Alzheimer's disease, diabetes, and epilepsy, had several medications not documented as administered across the three months. These medications included critical treatments for hypertension, diabetes, anxiety, and seizures, among others. Additionally, blood sugar readings were not documented on several occasions, which is particularly concerning given R1's diabetic condition. Despite the facility's policy requiring immediate documentation, these omissions persisted, raising concerns about the accuracy and reliability of R1's medication management. Similarly, R3, who was cognitively intact and had a range of health issues including diabetes, chronic obstructive pulmonary disease, and anxiety, also had numerous medications not documented as administered. These included medications for heart failure, anxiety, and diabetes, as well as blood sugar readings. Interviews with staff revealed that documentation was sometimes delayed due to the facility's busy environment, with nurses noting that they would document when time allowed. The Director of Nursing acknowledged the expectation for immediate documentation but did not provide additional information on why these deficiencies occurred, despite daily audits being conducted.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, resulting in the development of stage 3 pressure injuries. Resident R5, who was admitted with multiple health conditions including diabetes, chronic kidney disease, and incontinence, developed a stage 3 pressure injury on the sacrum. The facility did not conduct a comprehensive assessment or update the care plan to address R5's high risk for pressure injuries, despite the resident's dependency on staff for mobility and incontinence care. The care plan lacked specific instructions for repositioning frequency and did not account for R5's frequent loose stools due to C-diff, which increased the risk of skin breakdown. Resident R26, with diagnoses including chronic kidney disease and diabetes, also developed a stage 3 pressure injury on the coccyx. The initial assessment of the injury was incomplete and incorrectly staged as a stage 2, delaying appropriate treatment. The care plan was not revised promptly to reflect the new pressure injury, and there was a lack of comprehensive assessment to determine the need for increased repositioning and skin care interventions. The facility's failure to accurately assess and document the pressure injury contributed to inadequate care and delayed treatment. Both residents' care plans were not personalized to their specific needs, and there was a lack of timely updates and comprehensive assessments. The facility's policies on pressure injury prevention and care were not effectively implemented, leading to the development and progression of pressure injuries in these residents. The surveyor noted discrepancies in documentation and care plan revisions, highlighting systemic issues in the facility's approach to pressure ulcer management.
Inadequate Supervision and Care Plan Revisions Lead to Resident Falls and Smoking Risks
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, leading to multiple falls and injuries. One resident, with a history of falls and cognitive impairments, experienced several falls that were not thoroughly investigated, and the root causes were not determined. The care plan was not consistently revised to address the risks, and interventions were not always implemented, such as the use of a gait belt during transfers. This resident suffered a hip fracture and other injuries due to inadequate supervision and failure to follow the care plan. Another resident, who was assessed as requiring supervision while smoking, was found to be smoking alone without the necessary oversight. The facility's policy required that smoking materials be controlled by staff, but the resident reported having access to their own smoking materials and smoking unsupervised. This lack of supervision was contrary to the resident's care plan and the facility's smoking policy, which aimed to prevent smoking-related injuries. The facility's failure to conduct thorough investigations and revise care plans appropriately contributed to the ongoing safety risks for these residents. The lack of staff interviews and documentation of root causes for the falls, as well as the inconsistent application of safety interventions, highlighted deficiencies in the facility's approach to accident prevention and resident supervision.
Inadequate Staffing Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as observed during a survey. The Director of Nursing (DON) explained that staffing levels are determined based on the number of residents and their acuity needs, using a scheduling program called Smart Linx. However, the surveyor found that the facility was consistently short-staffed, particularly during the night (NOC) shifts, with missing Certified Nursing Assistants (CNAs) and nurses on several occasions. This staffing shortage was documented over multiple dates, both in the current year and the previous fiscal quarter, indicating a pattern of inadequate staffing. Residents expressed concerns about the insufficient staffing levels, which led to delayed responses to call lights. During a Resident Council meeting, residents reported long wait times for assistance, especially after medical procedures or surgeries. They noted that these delays were concerning, particularly if they experienced medical changes requiring more frequent assistance. One resident described the call light wait times as "horrible," and another resident confirmed witnessing prolonged call light activations for their neighbor. The surveyor noted discrepancies between the facility's daily schedules and actual timecard punches, suggesting inaccuracies in staffing records. Despite residents raising these concerns with the facility previously, they had not been informed of any resolutions or progress. The surveyor communicated these findings to the DON, but no further information was provided to explain why the facility failed to ensure adequate staffing to maintain the residents' well-being.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and served in accordance with professional standards for food service safety, potentially affecting all 30 residents. During an initial tour of the kitchen area, a surveyor observed several violations of food storage protocols. A jug of barbeque sauce was found sitting on the floor of the dry storage area, contrary to the facility's policy that requires all items to be stored on shelves at least six inches above the floor. Additionally, an open bag containing an unlabeled white powder was found on a shelf, and a bag of cheese omelets in the freezer was open and undated. In the lunch prep refrigerator, a container of hot dogs sitting in liquid and a pitcher with brown liquid were both found without labels or dates. The dietary manager was interviewed and acknowledged the observations, explaining that the barbeque sauce was used to prop open a door, which is against the facility's policy. The dietary manager stated that staff had been educated on the importance of not propping doors open with food products. The nursing home administrator was also informed of these observations, but no further information was provided at the time. These findings indicate a lack of adherence to the facility's food storage policies, which are based on the FDA Food Code, and highlight the need for improved compliance with food safety standards.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the outside garbage storage receptacles, as observed by a surveyor. The facility's policy, dated August 2017, requires that all garbage and refuse be collected and disposed of safely and efficiently. However, during an inspection, the surveyor observed a significant accumulation of debris, including 20 wood pallets, a refrigerator, and various garbage bags mixed with pine needles and pinecones, behind the dumpsters. The Dietary Manager was unsure about which staff was responsible for maintaining the cleanliness of the dumpster area, indicating a lack of clear responsibility and oversight. The Maintenance Director, upon being shown the area, expressed uncertainty about how to dispose of the refrigerator and pallets and acknowledged the need to regularly clean the area of pinecones and needles. Despite checking the area daily, the Maintenance Director had not addressed the accumulation of debris. The Nursing Home Administrator was informed of the situation and acknowledged the need to assist in resolving the issue, but at the time of the survey, no immediate corrective actions had been implemented to address the deficiency.
Inconsistent Weekend Staffing in Facility
Penalty
Summary
The facility did not ensure consistent staffing on weekends to meet the needs of the 30 residents residing in the facility. During the review of the payroll-based journal (PBJ) staffing data for the first quarter of the federal fiscal year 2023, the facility was flagged for excessively low weekend staffing. The facility's assessment indicated that the average daily census was between 28 to 32 residents, requiring 5 licensed nurses and 8 certified nursing assistants (CNAs) to provide direct care. The staffing requirements included having one registered nurse (RN) or licensed practical nurse (LPN) per shift, with specific ratios for day, PM, and night shifts. However, the facility's PBJ data revealed a discrepancy in staffing levels, particularly on weekends. The Director of Nursing (DON) stated that the facility's staffing needs are determined by the census and acuity of residents, using a scheduling program called Smart Linx. Despite the program's algorithm creating an ideal schedule, the facility was still triggered for low weekend staffing. The Regional Vice President (VP) acknowledged that the facility was automatically down 16 hours on weekends due to the absence of certain staff roles, such as the Minimum Data Set (MDS) nurse and Social Services. Additionally, a systemic issue was identified where agency staff hours were not being accurately pulled into the PBJ reporting, affecting the reported weekend staffing hours. This issue was attributed to a checkbox in Smart Linx not being checked, which led to agency hours not being integrated into the system, impacting the facility's staffing data.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which was evident from several deficiencies observed during the survey. The infection control logs for multiple months lacked critical information such as the date of onset, organism, and isolation type, and did not include resolved dates for infections. Baseline rates of infections were not calculated for several months, and a resident with C-Diff was not included in the infection log for February 2024. Additionally, infection control policies and procedures were not reviewed annually, and the Director of Nursing, who was supposed to be part of the water management team, was not involved in the program. The facility's water management program was inadequate, lacking specific flow charts and documentation of areas where water was flushed to prevent the spread of Legionella. The Maintenance Director was unable to provide a map or diagram showing dead ends in the water system and did not have records of when and where water was flushed. The water management plan was not included in the facility's assessment, and there was no documentation of flushing water in empty resident rooms, which could lead to stagnant water. Several infection control practices were not followed by staff, including a registered nurse touching medication with bare hands and a certified nursing assistant not washing hands between assisting residents to eat. A resident's urinary collection bag was observed lying directly on the floor, which is against the facility's catheter care policy. These actions and inactions contributed to the facility's failure to maintain a safe and sanitary environment for residents.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility did not provide a safe, clean, comfortable homelike environment, which had the potential to affect all residents eating in the dining room and two residents observed for care. Surveyors observed dining room staff serving meals on trays directly to residents in the dining room on multiple occasions. The Director of Nursing (DON) acknowledged the issue and stated it would be addressed with staff, but no further information was provided at the time of the surveyor's observation. Additionally, one resident's room had a strong urine odor and yellow stains on the bed sheet on multiple occasions. Despite the resident stating they did not need assistance with toileting, the surveyor noted the persistent odor and stains. Another resident was observed being repositioned by CNAs, who discovered a yellow stain and urine odor on the bedding. The CNAs took steps to address the issue, but the surveyor noted the deficiency in maintaining a clean and comfortable environment for the residents.
Deficiency in Code Status Documentation
Penalty
Summary
The facility failed to provide proper code status documentation for five residents, leading to a deficiency in adhering to residents' rights to formulate advance directives. For Resident 23, there was no documented code status upon admission, and the code status was only entered after the surveyor's inquiry. The Director of Nursing (DON) and Social Services staff were unable to provide evidence of prior documentation or communication regarding the resident's code status wishes. Resident 21 had a documented DNR status on the electronic record, but the state DNR form was not signed by the physician, leaving the resident's code status incomplete. The surveyor noted that the facility's process for confirming code status was inconsistent, with responsibilities shared between nursing staff and social services, but lacking a clear protocol for ensuring physician signatures on DNR forms. For Residents 5 and 10, the facility's records indicated a full code status, but there was no signed documentation or evidence of discussions with the residents to confirm their wishes. The facility relied on verbal confirmation and entries into the electronic system without a formalized process for obtaining written consent or documentation of the residents' code status preferences.
Failure to Address Pharmacy Recommendations in Medication Regimen Review
Penalty
Summary
The facility failed to ensure that recommendations made through the medication regimen review (MRR) were addressed for several residents, leading to deficiencies in medication management. For Resident 19, pharmacy recommendations to specify the dosage in grams for Diclofenac Sodium External Gel were repeatedly ignored over several months. Despite the recommendations being documented in November, December, and February, no follow-up actions were taken by the nursing staff, and the issue persisted until it was brought to the attention of the Director of Nursing (DON). Resident 2 also experienced a lack of follow-up on pharmacy recommendations. The pharmacist repeatedly recommended discontinuing Amitriptyline and conducting an AIMS assessment, but these recommendations were not addressed by the physician. The AIMS assessment was delayed until April, despite being recommended in December and February. Similarly, Resident 7's pharmacy recommendations regarding pain management were not addressed, with the physician failing to evaluate the use of Oxycodone and Tramadol as suggested by the pharmacist. Other residents, such as Resident 4 and Resident 26, also faced similar issues. Resident 4's pharmacy recommendations to reduce Ferrous Sulfate and conduct an AIMS assessment were not followed up on, and Resident 26's physician did not address recommendations to monitor therapy with specific tests. These repeated failures to act on pharmacy recommendations highlight a systemic issue within the facility's medication management processes.
Failure to Provide Required Medicare Coverage Notifications
Penalty
Summary
The facility failed to provide a resident with the necessary written beneficiary protection notifications when their Medicare Part A benefits ended. Specifically, the resident, identified as R7, did not receive an Advanced Beneficiary Notice (ABN), which should have included information about financial liability and appeal rights. The Notice of Medicare Non-Coverage (NOMNC) was also not provided, which is required to inform the resident or their representative that Medicare Part A coverage is ending, along with details on appeal rights and contact information for a third-party reviewer. During the survey, the regional vice president of success (VPS)-E confirmed that there was no ABN on file for the resident, despite the Medicare Part A Skilled Services episode having started on November 13, 2023, and ended on January 13, 2023. The social services coordinator (SSC)-I, who was new to the position, was unable to locate the necessary paperwork and acknowledged that it appeared the resident was never given the required forms to review or sign. The nursing home administrator (NHA)-A and VPS-E were informed of these concerns, but no additional information was provided at that time.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers to the hospital, including the necessary details such as the reason for transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This deficiency was identified for three residents who were hospitalized without receiving the required written transfer notices. The facility's policy on emergency transfers and discharges mandates that transfer notices be provided as soon as practicable, but this was not adhered to in the cases reviewed. For one resident, the medical records indicated hospitalization due to a mild heart attack, but there was no evidence of a written transfer notice being provided to the resident or their representative. Interviews with facility staff revealed a lack of clarity regarding who was responsible for issuing these notices. The Director of Nursing admitted to recently learning about the requirement to notify the ombudsman, which had not been done until late April. Another resident was transferred to the hospital following a fall, yet again, no written transfer notice was found in the medical records. The staff involved in the transfer process were unsure about the procedure for providing written notices. A third resident, who had multiple hospitalizations, also did not receive the required transfer notices. The facility's provided transfer forms lacked the necessary regulatory information, including appeal rights and ombudsman contact details, indicating a systemic issue in the facility's transfer notification process.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify residents and their representatives of the bed-hold policy during hospital transfers, as required by their own policy. This deficiency was identified for three residents (R7, R21, and R5) who were hospitalized. The facility's policy mandates that a notice of the bed-hold policy be provided to the resident and their representative at the time of transfer, or no later than 24 hours after the transfer. However, in these cases, no such notices were provided. Resident R7 was hospitalized following a mild heart attack and was admitted to the ICU. Despite the transfer and subsequent readmission to the facility, there was no documentation of the bed-hold policy being communicated to R7 or their representative. Interviews with facility staff revealed a lack of clarity regarding who was responsible for providing this information, with the LPN indicating it was the role of the Social Worker or Admission Coordinator, and the DON admitting unfamiliarity with the requirement. Similarly, Resident R21 was transferred to the hospital after a fall and admitted to the orthopedic floor. Again, there was no evidence of the bed-hold policy being communicated. Resident R5, who had multiple hospitalizations, also did not receive the required bed-hold information. Interviews with Social Services and the Regional VP confirmed the absence of documentation for R5, highlighting a systemic issue in the facility's process for handling bed-hold notifications.
Failure to Update PASARR for Resident with New Psychotic Disorder Diagnosis
Penalty
Summary
The facility failed to ensure that a resident, identified as R21, had an updated Preadmission Screening and Resident Review (PASARR) following a new diagnosis of a psychotic disorder with delusions. Initially admitted with various medical conditions, R21's level 1 PASARR dated June 23, 2022, indicated no mental illness, and thus, a level 2 screen was not required at that time. However, after being diagnosed with a psychotic disorder on June 26, 2023, the facility did not update the level 1 screen or initiate a level 2 referral, which is necessary for residents with mental health diagnoses. The surveyor's review of R21's medical records on April 28, 2024, revealed the absence of an updated level 1 screen or a level 2 PASARR. Despite the social service staff's belief that the paperwork had been completed and submitted to the prior nursing home administrator, there was no evidence of this in the records. The social service staff confirmed that a new level 1 screen was completed on April 30, 2024, but a level 2 screen had not yet been done. This oversight was communicated to the current nursing home administrator, director of nursing, and regional vice president.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R10, received necessary services to maintain good grooming, specifically in the area of showering. R10, who has multiple medical conditions including bilateral amputation, Type 2 Diabetes Mellitus, and chronic Congestive Heart Failure, was admitted to the facility and expressed that it was very important to choose between different types of bathing. Despite this, R10 reported not receiving a shower since admission and stated that staff did not offer one, although they assisted with washing up and dressing. The facility's policy requires that residents unable to perform activities of daily living receive necessary services, but documentation showed inconsistencies in providing showers to R10. The facility's records, including the Point of Care documentation and shower assignment logs, indicated that R10 was scheduled for showers twice a week, but there was a lack of evidence that these showers were provided. The surveyor's review of documentation from February to April revealed that R10's name appeared on the shower assignment sheets only twice, with one instance marked as a refusal. Interviews with staff, including a Registered Nurse and the VP of Clinical Services, revealed that there was no clear policy on shower frequency, and the facility relied on aides to document shower completion or refusal. The surveyor noted the absence of documentation for showers on several occasions, leading to the deficiency finding.
Deficiencies in Wound Care and Treatment Documentation
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds. For Resident 19, there was no comprehensive care plan in place for diuretic use or lymphedema treatments, and monitoring for adverse reactions was not conducted. The care plan and care Kardex were not updated to reflect the current treatment, and no orders for treatment or interventions could be located. Additionally, the resident was observed with leg wraps for lymphedema, but there were no orders or care plans addressing the use of these wraps or monitoring for adverse effects. Resident 25, who has a neoplasm on the perineal area, was not being properly assessed by nursing staff. The resident self-applied ointment for the condition, but staff did not verify or assist with the treatment, nor did they document any assessments of the wound. The facility's records showed inconsistencies in the documentation of wound assessments and treatments, with missing measurements and descriptions of the neoplasm's condition over time. Resident 26, with a venous stasis ulcer, did not receive treatments according to orders. The ulcer was not comprehensively assessed, and observations revealed that the wound was not cleaned during treatment. The treatment administration record was inaccurately initialed as completed, despite evidence to the contrary. Additionally, the wound physician was not informed of the ulcer, and the wound was not properly cleansed before dressing application, indicating a lack of adherence to proper wound care protocols.
Failure to Assess and Follow Up on Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident who was readmitted with an indwelling Foley catheter was assessed for its removal as soon as possible. The resident, who had multiple diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, and Hydronephrosis with renal and ureteral calculous obstruction, was discharged from the hospital with a Foley catheter for retention and a urology referral. However, the facility did not follow up with urology or assess the resident for catheter removal. The resident's medical records did not include a care plan for the Foley catheter, and there was inconsistent documentation regarding the resident's urinary continence status. The facility's Director of Nursing (DON) and staff failed to ensure that the resident's care plan and Kardex in Point Click Care (PCC) reflected the presence of the Foley catheter. Additionally, there was no evidence of an appointment being scheduled for the urology referral, and the facility's appointment book did not list any appointments for the resident. The facility's policy on catheter care did not include specific guidelines for assessing the need for catheter removal. The deficiency was identified during a survey when the surveyor noted the lack of follow-up and documentation regarding the resident's catheter care.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, as evidenced by the severe weight loss experienced by two residents, R5 and R21. R5, who was admitted with multiple diagnoses including Type 2 Diabetes Mellitus and Chronic Kidney Disease, experienced a significant weight loss of 48 pounds over three months. Despite the drastic changes in weight, neither the dietician nor the physician was notified, and no new interventions were implemented. The facility did not question the accuracy of the weights recorded, and re-weighs were not completed as per facility policy. R5's weight records showed inconsistencies, with a sudden drop from 185 pounds to 144.4 pounds within five days, and further to 100.4 pounds in another five days. These discrepancies were not addressed, and the dietician was not informed of these significant changes. The dietician, upon reviewing the records, noted the inconsistencies but was not notified in a timely manner to take corrective action. The lack of communication and failure to adhere to the weight monitoring policy contributed to the oversight in R5's care. Similarly, R21, who had a physician's order for weekly weights due to a history of weight loss, did not have weights recorded for several weeks. Although the medication administration record indicated that weights were taken, they were not documented in the medical record. This lack of documentation and monitoring led to a failure in following the physician's orders, further highlighting the facility's deficiency in maintaining proper nutritional monitoring and intervention for its residents.
Failure to Conduct Trauma-Informed Care Assessment
Penalty
Summary
The facility failed to comprehensively assess a resident for trauma-informed care and develop a personalized care plan to mitigate triggers and prevent re-traumatization. The facility's Trauma Informed Care Policy outlines the need for a multi-pronged approach to identify a resident's history of trauma and to document triggers that may cause re-traumatization. However, the surveyor found that the facility did not conduct a trauma-informed care assessment for a resident diagnosed with PTSD, anxiety disorder, and depressive disorder. The resident's care plan, initiated on November 7, 2023, included general interventions such as determining triggers, de-escalation preferences, and providing a safe environment. Despite these interventions, the CNA Kardex did not address the resident's PTSD or specific triggers. During an interview, the resident confirmed that no one at the facility had asked about her PTSD triggers, and she had not discussed her PTSD with the social worker, who was new to the facility. The surveyor's investigation revealed that the social service staff had not conducted trauma assessments, and the social worker was unsure if it was a requirement. The social worker later acknowledged the need to address the resident's PTSD diagnosis and care plan. The facility's failure to individualize the care plan and conduct a trauma-informed assessment led to the deficiency noted by the surveyor.
Failure to Monitor Vital Signs and Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary drugs, as required by regulations. For one resident with hypertension, the facility did not monitor the heart rate as per physician orders before administering Metoprolol Succinate ER, which was supposed to be held if the heart rate was less than 60. The resident's heart rate was not recorded in the medication administration record for March and April 2024, and the last recorded pulse was on April 11, 2024. Similarly, another resident with chronic diastolic heart failure and atrial fibrillation was not monitored for heart rate before receiving Metoprolol, despite physician orders to hold the medication if the heart rate was below 60. The last documented pulse for this resident was on February 29, 2024. Additionally, the facility administered Keflex, an antibiotic, to a resident without adequate signs or symptoms of a urinary tract infection (UTI). The resident returned from the hospital with a UTI diagnosis and an order for Keflex, but there was no documentation of urinary signs and symptoms prior to the hospital transfer. The Director of Nursing acknowledged that the resident did not meet the criteria for infection and that the antibiotic was continued at the request of the resident's granddaughter, despite the power of attorney not being activated. The hospital did not perform a culture and sensitivity test to confirm the need for the antibiotic.
High Medication Error Rate and Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 21.05%. This deficiency was identified through observations, interviews, and record reviews conducted by surveyors. Several instances of medication errors were noted, including the improper crushing of Metoprolol Succinate ER for a resident, which is against the facility's policy for extended-release medications. Additionally, a resident's Amlodipine Besylate was held without any physician-ordered parameters to justify the action. Further observations revealed that another resident did not receive multiple prescribed medications, including Farxiga, Isosorbide Mononitrate ER, Metoprolol Succinate ER, Prozac, and Spiriva inhaler, as ordered. The facility's documentation did not provide evidence that the physician was notified of these omissions, which spanned several days. Similarly, another resident did not receive Bumetanide as ordered, despite the medication being signed out as administered in the Medication Administration Record (MAR). The facility's policy on medication administration requires that medications be administered as prescribed and that any deviations, such as withholding or refusing medication, be documented with an explanatory note. However, the surveyor's findings indicated a lack of adherence to these protocols, contributing to the high medication error rate. The Director of Nursing was informed of these observations, but no additional information was provided to address the issues identified.
Improper Labeling of Insulin Pens
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding insulin pens. During an observation of the Deerpath medication cart, several insulin pens were found to be improperly labeled. An Insulin Aspart pen belonging to a resident was open and used but not dated when opened. A Levemir insulin flex pen lacked a label with a resident's name, although a torn white label with a name and date was noted. Another Aspart insulin pen and a Lantus insulin pen, both belonging to the same resident, were also open and used without being dated when opened. These deficiencies were brought to the attention of a Registered Nurse and the Director of Nursing, but no additional information was provided.
Uncertified Staff Feeding Resident
Penalty
Summary
The facility failed to ensure that a staff member, who was not a Certified Nursing Assistant (CNA), had completed a state-approved training course before feeding a resident. The Life Enrichment Specialist (LES) was observed feeding a resident, identified as R26, on two consecutive days without the necessary certification. The Director of Nursing confirmed that the facility did not have any paid feeding assistants and that the LES was not a CNA. The LES had previously worked as a hospitality aide at a sister facility and was not listed on the Wisconsin registry for CNAs. The resident, R26, had multiple diagnoses, including chronic kidney disease stage 5, diabetes mellitus, encephalopathy, and epilepsy. The care plan for R26 included various interventions related to nutritional and hydration status, as well as feeding strategies due to difficulty communicating. Despite these detailed care plans, the LES, who was not certified, was observed feeding R26 breakfast on two occasions. The resident's care plan required assistance with eating, and the LES was seen feeding the resident scrambled eggs without the appropriate certification. The surveyor's observations and interviews revealed that the LES had been working at the facility for about a month and was not aware of her CNA certification status. The facility's Regional Vice President and Director of Nursing were informed of the situation, and it was noted that the LES was relieved by a certified employee. The nurse's note documented that the resident did not experience any issues with swallowing during the feeding by the non-certified employee, but the incident highlighted a deficiency in ensuring that staff feeding residents are appropriately trained and certified.
Lack of Hospice Policy and Procedure in Facility
Penalty
Summary
The facility failed to ensure the presence of a hospice policy and procedure, which is crucial for designating a member of the Interdisciplinary Team (IDT) responsible for communicating with hospice services for the coordination of care. This deficiency was identified during a survey when the facility was unable to provide a hospice policy and procedure, affecting four residents receiving hospice services. Specifically, the surveyors noted that the facility did not have a hospice contract in their survey binder, and the Director of Nursing (DON) confirmed the absence of such a policy. This lack of policy meant there was no clear indication of who the representatives were between the facility and hospice for coordinating care, leaving staff without guidance on whom to contact. The deficiency was further highlighted in the cases of two residents, one of whom was admitted with severe protein calorie malnutrition and enrolled in hospice care. The other resident had multiple diagnoses, including chronic kidney disease and diabetes, and was receiving hospice care after refusing dialysis. The facility's hospice care plan for this resident included interventions such as medication administration and hospice staff visits but lacked specificity regarding the type of care required. The absence of a hospice policy meant there was no coordinated plan of care or clarity on the responsibilities of the facility and hospice staff, as confirmed by the DON during the survey.
Deficiency in Immunization Documentation for Residents
Penalty
Summary
The facility failed to ensure that three residents were offered and documented for influenza and pneumococcal immunizations, as required by their policies. The medical records for these residents did not contain any documentation indicating whether they received or refused these vaccines. This lack of documentation was identified during a survey, which revealed that the facility did not have the necessary immunization information until it was requested by the surveyor. Resident 5's medical record lacked documentation of influenza and pneumococcal vaccinations, although the Wisconsin Immunization Registry (WIR) later confirmed that the resident had received these vaccines. Similarly, Resident 332's medical record did not show any information about these vaccines, but the WIR indicated that the resident had received them. Resident 26's record showed an influenza vaccination but lacked documentation for the pneumococcal vaccine, which was later confirmed through the WIR. The Director of Nursing, who oversees the immunization program, explained that the facility's process involves reviewing vaccination history and obtaining consent during admission. However, the surveyor found that this process was not effectively documented in the residents' medical records, leading to the identified deficiencies.
Failure to Ensure Appropriate Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for two residents, R7 and R25. R7, who has a history of hemiplegia, anxiety disorder, depressive disorder, diabetes mellitus, chronic pulmonary disease, and congestive heart failure, was observed with a bottle of artificial tears and Fluticasone Propionate nasal spray on her over-bed table. Despite having a BIMS score indicating cognitive intactness, there was no self-medication assessment or physician order for R7 to self-administer these medications. The Director of Nursing confirmed that no self-administration assessments were conducted in the facility. R25, diagnosed with discitis, carcinoma in situ of the anus, anemia, Hodgkin lymphoma, and paresthesia, was performing his own perineum wound treatment without an assessment or physician order. R25 was applying a triple antibiotic ointment and a menthol-methyl salicylate cream for pain management without nursing staff oversight. The surveyor noted that the nursing staff was signing off on the treatment administration record as if they had completed the treatments, despite R25 self-administering them. R25 stated that he did not refuse staff assistance, yet the nursing staff claimed he did not allow them to apply treatments. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents who wish to self-administer medications. However, this protocol was not followed for R7 and R25, leading to a deficiency in ensuring the safety and appropriateness of self-medication practices. The lack of proper assessments and documentation highlights a failure in adhering to the facility's self-administration policy, as observed by the surveyor.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Menomonee Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lindengrove Menomonee Falls | 0 mi | — | 15 | 1 |
| Congregational Home, Inc. | 5.1 mi | — | 0 | 0 |
| Luther Manor | 5.4 mi | — | 17 | 0 |
| Complete Care At Germantown | 5.6 mi | — | 0 | 0 |
| Amethyst Health Of Brown Deer | 5.9 mi | — | 54 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.