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Deficiency Records for Menomonee Falls Health Services
A list of the most recent deficiencies for Menomonee Falls Health Services. 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 Menomonee Falls Health Services. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-02 | 2024-06-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-05-02 | 2024-06-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-01 | 2024-06-06 | 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 | 2024-05-01 | 2024-06-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-01 | 2024-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-01 | 2024-06-06 | 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 | 2024-05-01 | 2024-06-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-05-01 | 2024-06-06 | 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 | 2024-05-01 | 2024-06-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-01 | 2024-06-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-01 | 2024-06-06 | 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 | 2024-05-01 | 2024-06-06 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2024-05-01 | 2024-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-01 | 2024-06-06 | N |
| Dispose of garbage and refuse properly. | Health | 2024-05-01 | 2024-06-06 | N |
| 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 | 2024-05-01 | 2024-06-06 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-05-01 | 2024-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-01 | 2024-06-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-01 | 2024-06-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-05-01 | 2024-06-06 | Y |
| 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 | 2024-05-01 | 2024-06-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-02 | 2024-06-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-18 | 2024-01-16 | Y |
| Provide appropriate foot care. | Health | 2023-12-18 | 2024-01-16 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-21 | 2023-04-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-21 | 2023-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-21 | 2023-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-21 | 2023-04-28 | 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 | 2023-03-21 | 2023-04-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-04-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-23 | 2023-04-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-23 | 2023-04-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-23 | 2023-04-21 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-21 | 2023-04-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-21 | 2023-04-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-19 | 2022-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-06 | 2022-02-06 | 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 | 2022-01-06 | 2022-02-06 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-01-06 | 2022-02-06 | Y |
| 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 | 2022-01-06 | 2022-02-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-06 | 2022-02-06 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-04 | 2022-02-06 | 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 | 2022-01-04 | 2022-02-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-10-14 | 2021-11-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-14 | 2021-11-16 | 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 | 2021-10-14 | 2021-11-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-14 | 2021-11-16 | 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 | 2021-10-14 | 2021-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-14 | 2021-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-11-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-14 | 2021-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-14 | 2021-11-16 | Y |
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