A list of the most recent deficiencies for Waunakee Valley Senior Living. 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 special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-04 | 2024-02-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-01-04 | 2024-02-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-08 | 2024-02-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-08 | 2024-02-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-08 | 2024-02-05 | N |
| 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 | 2024-01-08 | 2024-02-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-08 | 2024-02-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-08 | 2024-02-05 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-04 | 2024-02-01 | N |
| Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Fire Safety | 2024-01-04 | 2024-02-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-04 | 2024-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-04 | 2024-02-01 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-01-04 | 2024-02-01 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-04 | 2024-02-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-04 | 2024-02-01 | 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 | 2023-02-17 | 2023-02-18 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-08 | 2023-01-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-12-08 | 2023-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2023-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-08 | 2023-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-08 | 2023-01-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-08 | 2023-01-10 | 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 | 2022-12-08 | 2023-01-10 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-12-08 | 2023-01-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-08 | 2023-01-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-12-08 | 2023-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2023-01-10 | 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 | 2022-12-08 | 2023-01-10 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2022-12-08 | 2023-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2023-01-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-08 | 2023-01-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-08 | 2023-01-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-12-08 | 2023-01-10 | 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 | 2022-12-08 | 2023-01-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-12-06 | 2023-01-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-12-06 | 2023-01-10 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-12-06 | 2023-01-10 | 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 | 2022-12-06 | 2023-01-10 | 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 | 2022-12-06 | 2023-01-10 | 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 | 2022-12-06 | 2023-01-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-06 | 2023-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-06 | 2023-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-06 | 2023-01-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-06 | 2023-01-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-12-06 | 2023-01-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-12-06 | 2023-01-10 | 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 | 2022-11-01 | 2022-11-10 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-11-01 | 2022-11-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-01 | 2022-11-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-01 | 2022-11-04 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-01 | 2022-11-04 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-11-01 | 2022-11-04 | 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 | 2022-10-03 | 2022-10-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-03 | 2022-10-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-03 | 2022-10-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-03 | 2022-10-31 | 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 | 2022-10-03 | 2022-10-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-03 | 2022-10-31 | 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 | 2022-10-03 | 2022-10-31 | Y |
| Post nurse staffing information every day. | Health | 2022-10-03 | 2022-10-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-03 | 2022-10-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-03 | 2022-10-31 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-03 | 2022-10-31 | 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 | 2022-07-29 | 2022-10-05 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-29 | 2022-10-05 | 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 | 2022-07-29 | 2022-09-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-29 | 2022-09-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-21 | 2022-09-11 | 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 | 2022-07-21 | 2022-09-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-21 | 2022-09-11 | 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 | 2022-07-21 | 2022-09-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-21 | 2022-09-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-07-21 | 2022-09-11 | Y |
| Post nurse staffing information every day. | Health | 2022-07-21 | 2022-09-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-21 | 2022-09-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-21 | 2022-09-11 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-07-21 | 2022-09-11 | 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 | 2022-07-21 | 2022-09-11 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-21 | 2022-09-11 | 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 | 2022-07-21 | 2022-09-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-21 | 2022-09-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-21 | 2022-09-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-21 | 2022-09-11 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2021-08-05 | 2021-11-10 | 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 | 2021-08-05 | 2021-11-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-05 | 2021-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-10 | 2021-09-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-10 | 2021-09-10 | 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 | 2021-08-10 | 2021-09-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-10 | 2021-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-10 | 2021-09-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-05 | 2021-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-05 | 2021-09-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-05 | 2021-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-08 | 2021-04-06 | Y |
