A list of the most recent deficiencies for Crossroads Care Center of Weyauwega. 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 | 2023-11-01 | 2023-11-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-01 | 2023-11-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-15 | 2023-03-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-15 | 2023-03-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-28 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-01-12 | 2023-02-28 | 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 | 2023-01-12 | 2023-02-28 | 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 | 2023-01-12 | 2023-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-12 | 2023-02-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-12 | 2023-02-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-12 | 2023-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-02-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-12 | 2023-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-12 | 2023-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-12 | 2023-02-14 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-01-12 | 2023-02-14 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-01-12 | 2023-02-06 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-12 | 2023-02-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-10 | 2022-12-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-09 | 2022-07-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-01 | 2022-03-04 | 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 | 2022-02-01 | 2022-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-01 | 2022-03-04 | N |
| Respond appropriately to all alleged violations. | Health | 2022-02-01 | 2022-03-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-01-31 | 2022-02-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-01-31 | 2022-02-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-01-31 | 2022-02-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-31 | 2022-02-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-31 | 2022-02-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-31 | 2022-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-04 | 2021-11-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-04 | 2021-11-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-30 | 2021-09-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-03 | 2021-09-03 | 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 | 2021-05-24 | 2021-06-23 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-24 | 2021-06-23 | Y |
| Post nurse staffing information every day. | Health | 2021-05-24 | 2021-06-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-24 | 2021-06-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-03-09 | 2021-04-10 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-03-11 | 2021-04-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-03-11 | 2021-04-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-11 | 2021-04-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-11 | 2021-04-07 | N |
| Post nurse staffing information every day. | Health | 2021-03-11 | 2021-04-07 | 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 | 2021-03-11 | 2021-04-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-11 | 2021-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-11 | 2021-04-07 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-03-09 | 2021-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-14 | Not Fixed | Y |
