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Deficiency Records for Beaver Dam Health Care Center
A list of the most recent deficiencies for Beaver Dam Health Care Center. 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 Beaver Dam Health Care Center. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2024-07-16 | 2024-08-06 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-07-16 | 2024-08-06 | 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 | 2024-06-25 | 2024-07-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-25 | 2024-07-25 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-06-25 | 2024-07-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-25 | 2024-07-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-25 | 2024-07-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-06-25 | 2024-07-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-06-25 | 2024-07-25 | Y |
| Post nurse staffing information every day. | Health | 2024-06-25 | 2024-07-25 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-06-25 | 2024-07-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-07 | 2024-04-03 | N |
| 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 | 2024-03-07 | 2024-04-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-07 | 2024-04-03 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-07 | 2024-04-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-07 | 2024-04-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-07 | 2024-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-07 | 2024-04-03 | 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 | 2024-03-07 | 2024-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-07 | 2024-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-04-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-07 | 2024-04-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-07 | 2024-04-03 | N |
| Keep all essential equipment working safely. | Health | 2024-03-07 | 2024-04-03 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-07 | 2024-04-03 | 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 | 2024-03-07 | 2024-04-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-07 | 2024-04-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-29 | 2024-02-28 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-01-29 | 2024-02-28 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-01-29 | 2024-02-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-29 | 2024-02-16 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-01-29 | 2024-02-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-29 | 2024-02-13 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-01-29 | 2024-02-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-29 | 2024-02-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-13 | 2024-01-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-13 | 2024-01-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-13 | 2024-01-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-13 | 2024-01-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-13 | 2024-01-08 | Y |
| Help the resident with transportation to and from laboratory services outside of the facility. | Health | 2023-12-13 | 2024-01-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-30 | 2023-11-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-30 | 2023-11-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-30 | 2023-11-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-30 | 2023-09-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-30 | 2023-09-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-07 | 2023-08-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-14 | 2023-07-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-14 | 2023-07-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-10 | 2023-06-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-10 | 2023-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-10 | 2023-06-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-10 | 2023-06-01 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-04-18 | 2023-05-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-20 | 2023-04-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-20 | 2023-04-17 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-19 | 2023-01-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-19 | 2023-01-16 | N |
| Respond appropriately to all alleged violations. | Health | 2022-12-19 | 2023-01-16 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-12-19 | 2023-01-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-19 | 2023-01-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-19 | 2023-01-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-19 | 2023-01-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-19 | 2023-01-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-12-19 | 2023-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-19 | 2023-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-19 | 2023-01-16 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-19 | 2023-01-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-19 | 2023-01-16 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-19 | 2023-01-16 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2022-12-19 | 2023-01-16 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-12-19 | 2023-01-16 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2022-12-19 | 2023-01-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-12-19 | 2023-01-16 | N |
| 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 | 2022-12-19 | 2023-01-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-19 | 2023-01-16 | Y |
| 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 | 2022-12-19 | 2023-01-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-19 | 2023-01-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-19 | 2023-01-16 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-12-12 | 2023-01-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-26 | 2022-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-26 | 2022-10-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-26 | 2022-10-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-26 | 2022-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-26 | 2022-10-18 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-09-26 | 2022-10-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-26 | 2022-10-18 | 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 | 2022-09-26 | 2022-10-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-02 | 2022-05-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-02 | 2022-05-27 | 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 | 2021-09-30 | 2022-01-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-29 | 2021-12-21 | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2021-09-29 | 2021-10-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-29 | 2021-10-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-29 | 2021-10-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-29 | 2021-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-29 | 2021-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-29 | 2021-10-28 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-29 | 2021-10-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-29 | 2021-10-28 | 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 | 2021-09-30 | 2021-10-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-30 | 2021-10-26 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2021-09-30 | 2021-10-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-30 | 2021-10-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-09-30 | 2021-10-08 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-09-30 | 2021-10-08 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-09-30 | 2021-10-01 | N |
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