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Deficiency Records for Alexian Village of Milwaukee
A list of the most recent deficiencies for Alexian Village of Milwaukee. 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 Alexian Village of Milwaukee. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-01 | 2024-08-21 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-01 | 2024-08-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-01 | 2024-08-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-01 | 2024-08-06 | Y |
| Provide appropriate foot care. | Health | 2024-07-01 | 2024-08-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-01 | 2024-08-06 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-01 | 2024-08-06 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-01 | 2024-08-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-01 | 2024-08-06 | Y |
| 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 | 2024-07-01 | 2024-08-06 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-07-01 | 2024-08-06 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-07-01 | 2024-08-06 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-07-01 | 2024-08-06 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-07-01 | 2024-08-06 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-07-01 | 2024-08-06 | Y |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-07-01 | 2024-08-06 | Y |
| Provide training in compliance and ethics. | Health | 2024-07-01 | 2024-08-06 | 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 | 2024-07-01 | 2024-08-06 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-07-01 | 2024-08-06 | Y |
| 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 | 2024-04-08 | 2024-05-07 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-07 | 2023-09-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-07 | 2023-09-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-09 | 2023-09-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-09 | 2023-09-09 | 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 | 2023-08-09 | 2023-09-09 | 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 | 2023-08-09 | 2023-09-09 | 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 | 2023-08-09 | 2023-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-09 | 2023-09-09 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2023-08-07 | 2023-09-09 | 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 | 2023-08-07 | 2023-09-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-07 | 2023-09-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-08 | 2023-03-31 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-13 | 2022-05-13 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-04-13 | 2022-05-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-11 | 2022-05-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-07 | 2020-04-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-18 | 2020-03-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-02-18 | 2020-03-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-02-18 | 2020-03-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-18 | 2020-03-03 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-18 | 2020-03-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-18 | 2020-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-18 | 2020-03-03 | 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 | 2020-02-18 | 2020-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-18 | 2020-03-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-18 | 2020-03-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-18 | 2020-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-18 | 2020-03-03 | N |
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