A list of the most recent deficiencies for Middleton Village Nursing and Rehab. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-23 | 2024-02-08 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-24 | 2023-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-24 | 2023-12-06 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-10-24 | 2023-12-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-24 | 2023-11-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-10-26 | 2023-11-17 | 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 | 2023-10-26 | 2023-11-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-26 | 2023-11-17 | N |
| Provide activities to meet all resident's needs. | Health | 2023-10-26 | 2023-11-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-26 | 2023-11-17 | 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 | 2023-10-26 | 2023-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-17 | 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 | 2023-10-26 | 2023-11-17 | 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 | 2023-10-26 | 2023-11-17 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-10-26 | 2023-11-17 | N |
| Dispose of garbage and refuse properly. | Health | 2023-10-26 | 2023-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-26 | 2023-11-17 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-26 | 2023-11-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-26 | 2023-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2023-11-17 | 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 | 2023-10-26 | 2023-11-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-26 | 2023-11-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-26 | 2023-11-17 | Y |
| 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 | 2023-10-24 | 2023-11-17 | 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 | 2023-10-24 | 2023-11-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-24 | 2023-11-17 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2023-06-21 | 2023-07-12 | 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 | 2023-06-21 | 2023-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-21 | 2023-07-12 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-21 | 2023-07-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-21 | 2023-07-12 | Y |
| Help the resident with transportation to and from laboratory services outside of the facility. | Health | 2023-06-21 | 2023-07-12 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-06-21 | 2023-07-12 | 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 | 2023-06-21 | 2023-07-12 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-21 | 2023-07-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-21 | 2023-07-12 | 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 | 2023-06-21 | 2023-07-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-21 | 2023-06-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-18 | 2022-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-09-13 | 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 | 2022-08-18 | 2022-09-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-18 | 2022-09-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-18 | 2022-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-18 | 2022-09-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-18 | 2022-09-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-18 | 2022-09-13 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-17 | 2022-09-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-08-17 | 2022-09-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-17 | 2022-09-05 | 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 | 2022-08-17 | 2022-09-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-17 | 2022-08-29 | 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 | 2022-08-17 | 2022-08-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-17 | 2022-08-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-17 | 2022-08-18 | 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 | 2022-06-02 | 2022-06-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-06-02 | 2022-06-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-02 | 2022-06-22 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-06-02 | 2022-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-06-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-02 | 2022-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-03 | 2022-02-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-03 | 2022-02-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-03 | 2022-02-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-25 | 2021-11-04 | 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 | 2021-10-06 | 2021-10-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-06 | 2021-10-25 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-10-06 | 2021-10-25 | 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 | 2021-10-06 | 2021-10-25 | Y |
| Report COVID19 data to residents and families. | Health | 2021-10-06 | 2021-10-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-31 | 2021-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-31 | 2021-09-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-06 | 2021-07-14 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-04 | 2021-06-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-04 | 2021-06-14 | 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 | 2021-06-01 | 2021-06-11 | 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 | 2021-06-01 | 2021-06-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-06 | 2021-06-02 | 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 | 2021-05-06 | 2021-06-02 | N |
| Provide activities to meet all resident's needs. | Health | 2021-05-06 | 2021-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-06 | 2021-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-06 | 2021-06-02 | 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 | 2021-05-06 | 2021-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-06 | 2021-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-06 | 2021-06-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-05-06 | 2021-06-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-05-06 | 2021-06-02 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-05-06 | 2021-06-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-06 | 2021-06-02 | Y |
| 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 | 2021-05-06 | 2021-06-02 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-05-06 | 2021-06-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-06 | 2021-06-02 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2021-05-04 | 2021-06-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-04 | 2021-06-01 | 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 | 2021-05-04 | 2021-06-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-05-04 | 2021-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-04 | 2021-06-01 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-05-04 | 2021-06-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-04 | 2021-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | Not Fixed | N |
