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Deficiency Records for Middleton Village Nursing and Rehab

A list of the most recent deficiencies for Middleton Village Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Middleton Village Nursing and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-10-24 2024-08-12 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2024-05-24 2024-06-04 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-05-24 2024-06-04 Y
Develop, implement, and/or maintain an effective training program for all new and existing staff members. Health 2024-05-24 2024-06-04 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-05-16 2024-06-04 Y
Respond appropriately to all alleged violations. Health 2024-05-16 2024-06-04 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-05-16 2024-06-04 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-05-16 2024-06-04 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-04-24 2024-05-16 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-04-24 2024-05-16 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-04-18 2024-05-10 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-04-18 2024-05-10 Y
Respond appropriately to all alleged violations. Health 2024-04-18 2024-05-10 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-04-18 2024-05-10 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-04-18 2024-04-18 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-02-12 2024-02-19 Y
Respond appropriately to all alleged violations. Health 2024-02-12 2024-02-19 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-01-23 2024-02-08 Y
Install corridor and hallway doors that block smoke. Fire Safety 2023-10-24 2023-12-08 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-10-24 2023-12-06 N
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Fire Safety 2023-10-24 2023-12-04 N
Install an approved automatic sprinkler system. Fire Safety 2023-10-24 2023-11-21 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-10-26 2023-11-17 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2023-10-26 2023-11-17 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-10-26 2023-11-17 N
Provide activities to meet all resident's needs. Health 2023-10-26 2023-11-17 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-10-26 2023-11-17 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2023-10-26 2023-11-17 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-10-26 2023-11-17 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2023-10-26 2023-11-17 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2023-10-26 2023-11-17 N
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Health 2023-10-26 2023-11-17 N
Dispose of garbage and refuse properly. Health 2023-10-26 2023-11-17 N
Provide and implement an infection prevention and control program. Health 2023-10-26 2023-11-17 N
Implement a program that monitors antibiotic use. Health 2023-10-26 2023-11-17 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-10-26 2023-11-17 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-10-26 2023-11-17 Y
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2023-10-26 2023-11-17 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-10-26 2023-11-17 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-10-26 2023-11-17 Y
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2023-10-24 2023-11-17 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-10-24 2023-11-17 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-10-24 2023-11-17 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-10-24 2023-11-17 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2023-10-24 2023-11-17 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-10-24 2023-11-17 N
Honor the resident's right to choose his or her attending physician. Health 2023-06-21 2023-07-12 Y
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2023-06-21 2023-07-12 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-06-21 2023-07-12 Y
Observe each nurse aide's job performance and give regular training. Health 2023-06-21 2023-07-12 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-06-21 2023-07-12 Y
Help the resident with transportation to and from laboratory services outside of the facility. Health 2023-06-21 2023-07-12 Y
Provide routine and 24-hour emergency dental care for each resident. Health 2023-06-21 2023-07-12 Y
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2023-06-21 2023-07-12 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-06-21 2023-07-12 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-06-21 2023-07-12 Y
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2023-06-21 2023-07-12 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-06-21 2023-06-21 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-08-18 2022-09-13 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-18 2022-09-13 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2022-08-18 2022-09-13 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-08-18 2022-09-13 N
Ensure medication error rates are not 5 percent or greater. Health 2022-08-18 2022-09-13 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-08-18 2022-09-13 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-08-18 2022-09-13 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-08-18 2022-09-13 Y
Install an approved automatic sprinkler system. Fire Safety 2022-08-17 2022-09-07 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2022-08-17 2022-09-07 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2022-08-17 2022-09-05 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-08-17 2022-09-02 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2022-08-17 2022-08-29 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2022-08-17 2022-08-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-08-17 2022-08-24 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2022-08-17 2022-08-18 N
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2022-06-02 2022-06-22 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2022-06-02 2022-06-22 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2022-06-02 2022-06-22 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2022-06-02 2022-06-22 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-02 2022-06-22 Y
Ensure that residents are free from significant medication errors. Health 2022-06-02 2022-06-22 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-02-03 2022-02-24 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-02-03 2022-02-24 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-02-03 2022-02-24 Y
Provide and implement an infection prevention and control program. Health 2022-02-03 2022-02-24 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-10-25 2021-11-04 Y
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2021-10-06 2021-10-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-10-06 2021-10-25 Y
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2021-10-06 2021-10-25 Y
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Health 2021-10-06 2021-10-25 Y
Report COVID19 data to residents and families. Health 2021-10-06 2021-10-25 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-05-06 2021-07-14 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-05-04 2021-06-15 N
Construct fire resistant interior walls. Fire Safety 2021-05-04 2021-06-14 N
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Health 2021-05-06 2021-06-02 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2021-05-06 2021-06-02 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-05-06 2021-06-02 N
Provide activities to meet all resident's needs. Health 2021-05-06 2021-06-02 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-05-06 2021-06-02 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2021-05-06 2021-06-02 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-05-06 2021-06-02 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2021-05-06 2021-06-02 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2021-05-06 2021-06-02 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2021-05-06 2021-06-02 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-05-06 2021-06-02 N
Provide and implement an infection prevention and control program. Health 2021-05-06 2021-06-02 N
Implement a program that monitors antibiotic use. Health 2021-05-06 2021-06-02 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-05-06 2021-06-02 N
Establish emergency prep training and testing. Fire Safety 2021-05-04 2021-06-01 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2021-05-04 2021-06-01 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2021-05-04 2021-06-01 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2021-05-04 2021-06-01 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-05-04 2021-06-01 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2021-05-04 2021-06-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-05-04 2021-06-01 N

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