A list of the most recent deficiencies for Menomonee Falls Health Services. 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 pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-18 | 2024-01-16 | Y |
| Provide appropriate foot care. | Health | 2023-12-18 | 2024-01-16 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-21 | 2023-04-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-03-21 | 2023-04-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-21 | 2023-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-21 | 2023-04-28 | 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 | 2023-03-21 | 2023-04-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-21 | 2023-04-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-23 | 2023-04-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-23 | 2023-04-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-03-23 | 2023-04-21 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-21 | 2023-04-21 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-03-21 | 2023-04-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-21 | 2023-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-19 | 2022-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-06 | 2022-02-06 | 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 | 2022-01-06 | 2022-02-06 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-01-06 | 2022-02-06 | Y |
| 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 | 2022-01-06 | 2022-02-06 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-06 | 2022-02-06 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-04 | 2022-02-06 | 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 | 2022-01-04 | 2022-02-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-01-04 | 2022-02-06 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2021-10-14 | 2021-11-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-14 | 2021-11-16 | 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 | 2021-10-14 | 2021-11-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-14 | 2021-11-16 | 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 | 2021-10-14 | 2021-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-14 | 2021-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-11-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-14 | 2021-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-14 | 2021-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-27 | 2021-11-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-27 | 2021-10-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-27 | 2021-10-14 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-07-27 | 2021-10-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-27 | 2021-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-10-14 | 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 | 2021-07-27 | 2021-10-14 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-09-25 | 2019-10-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-09-25 | 2019-10-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-25 | 2019-10-25 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2019-09-25 | 2019-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-25 | 2019-10-25 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide or obtain dental services for each resident. | Health | 2019-09-25 | 2019-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-25 | 2019-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-25 | 2019-10-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-25 | 2019-10-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-26 | 2019-10-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-26 | 2019-10-25 | N |
