A list of the most recent deficiencies for The Manor of Kenosha. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-13 | 2023-11-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-02 | 2023-03-02 | 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 | 2023-02-02 | 2023-03-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-02-02 | 2023-03-02 | 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 | 2023-02-02 | 2023-03-02 | 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 | 2023-02-02 | 2023-03-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-02 | 2023-03-02 | 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 | 2023-02-02 | 2023-03-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-03-02 | N |
| Keep all essential equipment working safely. | Health | 2023-02-02 | 2023-03-02 | 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 | 2023-02-02 | 2023-03-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-02 | 2023-03-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-02 | 2023-03-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-02 | 2023-03-02 | 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 | 2023-02-02 | 2023-03-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-02 | 2023-03-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-02 | 2023-03-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-02 | Y |
| Install resident room doors of proper design and width. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-26 | 2023-03-02 | 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 | 2023-01-26 | 2023-03-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-26 | 2023-03-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-03 | 2022-12-02 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-03 | 2022-12-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-03 | 2022-12-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-03 | 2022-12-02 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-03 | 2022-12-02 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-03 | 2022-12-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-03 | 2022-12-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-03 | 2022-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-03 | 2022-12-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-21 | 2022-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-21 | 2022-01-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-21 | 2022-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2022-01-06 | 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 | 2021-12-15 | 2022-01-06 | Y |
| 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 | 2021-12-15 | 2022-01-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-15 | 2022-01-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-15 | 2022-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-15 | 2022-01-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-15 | 2022-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-15 | 2022-01-06 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-15 | 2022-01-06 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-21 | 2021-12-15 | 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 | 2021-10-21 | 2021-12-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-21 | 2021-12-15 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-10-21 | 2021-12-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-21 | 2021-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-21 | 2021-12-15 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-19 | 2021-11-17 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-19 | 2021-11-11 | 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 | 2021-10-19 | 2021-11-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2021-10-19 | 2021-11-11 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-08-10 | 2021-08-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-10 | 2021-08-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-10 | 2021-08-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-28 | 2021-05-25 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-28 | 2021-05-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-28 | 2021-05-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-28 | 2021-05-25 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-04-28 | 2021-05-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-28 | 2021-05-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-23 | 2019-10-23 | 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 | 2019-09-23 | 2019-10-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-23 | 2019-10-23 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-23 | 2019-10-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-23 | 2019-10-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-23 | 2019-10-23 | 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 | 2019-09-23 | 2019-10-23 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-23 | 2019-10-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-23 | 2019-10-23 | 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 | 2019-09-23 | 2019-10-23 | 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 | 2019-09-23 | 2019-10-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-23 | 2019-10-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-23 | 2019-10-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-17 | 2019-10-23 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-17 | 2019-10-23 | 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 | 2019-09-17 | 2019-10-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-09-17 | 2019-10-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-17 | 2019-10-23 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-17 | 2019-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-17 | 2019-10-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-17 | 2019-10-23 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2019-09-17 | 2019-10-23 | N |
