A list of the most recent deficiencies for Waterfall Health of Brown Deer. 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? |
|---|---|---|---|---|
| Have exits that are accessible at all times. | Fire Safety | 2023-09-11 | 2023-11-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-13 | 2023-10-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-13 | 2023-10-12 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-13 | 2023-10-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-13 | 2023-10-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-13 | 2023-10-12 | Y |
| Provide appropriate foot care. | Health | 2023-09-13 | 2023-10-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-13 | 2023-10-12 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-13 | 2023-10-12 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-13 | 2023-10-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-13 | 2023-10-12 | Y |
| 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 | 2023-09-13 | 2023-10-12 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-09-13 | 2023-10-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-10-12 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-11 | 2023-10-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-11 | 2023-10-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-09-11 | 2023-10-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-11 | 2023-10-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-11 | 2023-10-07 | 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 | 2023-09-11 | 2023-10-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-11 | 2023-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-11 | 2023-10-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-11 | 2023-10-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-11 | 2023-10-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-09-11 | 2023-10-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-11 | 2023-10-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-07 | 2023-07-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-07 | 2023-07-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-28 | 2022-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-28 | 2022-10-21 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-09-28 | 2022-10-21 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-15 | 2022-07-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-15 | 2022-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-19 | 2022-07-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-04-14 | 2022-07-18 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-14 | 2022-07-18 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-20 | 2022-07-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-20 | 2022-07-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-06-20 | 2022-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-20 | 2022-07-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | 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 | 2022-06-20 | 2022-07-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-20 | 2022-07-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-20 | 2022-07-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-20 | 2022-07-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-20 | 2022-07-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-20 | 2022-07-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-20 | 2022-07-18 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-06-20 | 2022-07-18 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-15 | 2022-07-18 | 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 | 2022-06-15 | 2022-07-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-15 | 2022-07-18 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-04-29 | 2022-06-06 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-19 | 2022-06-06 | 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 | 2022-04-19 | 2022-06-06 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-04-19 | 2022-06-06 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-04-19 | 2022-06-06 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-04-19 | 2022-06-06 | Y |
| Ensure a qualified health professional conducts resident assessments. | Health | 2022-04-19 | 2022-06-06 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-04-19 | 2022-06-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-19 | 2022-06-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-19 | 2022-06-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-14 | 2022-06-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-14 | 2022-06-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-14 | 2022-06-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-04-14 | 2022-06-06 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-04-14 | 2022-06-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-14 | 2022-06-06 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-04-14 | 2022-06-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-14 | 2022-06-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-14 | 2022-06-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-06-06 | Y |
| 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 | 2022-04-14 | 2022-06-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-14 | 2022-06-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-14 | 2022-06-06 | 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 | 2022-04-14 | 2022-06-06 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-04-14 | 2022-06-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-14 | 2022-06-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-14 | 2022-06-06 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-04-14 | 2022-06-06 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-25 | 2022-02-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-25 | 2022-02-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-25 | 2022-02-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-25 | 2022-02-23 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-25 | 2022-02-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-25 | 2022-02-23 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2022-01-25 | 2022-02-23 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-01-25 | 2022-02-23 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-01-25 | 2022-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-25 | 2022-02-23 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-25 | 2022-02-23 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-01-25 | 2022-02-23 | 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 | 2022-01-25 | 2022-02-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-25 | 2022-02-09 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-25 | 2022-02-09 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-03 | 2021-11-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-03 | 2021-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-11-09 | Y |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-11-03 | 2021-11-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-03 | 2021-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-03 | 2021-04-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-03 | 2021-04-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-03 | 2021-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-03 | 2021-04-08 | N |
| 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 | 2021-03-03 | 2021-04-08 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-03-03 | 2021-04-08 | 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 | 2021-03-03 | 2021-04-08 | 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 | 2021-03-03 | 2021-04-08 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2021-03-03 | 2021-04-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-03-03 | 2021-04-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-03 | 2021-04-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-03 | 2021-04-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-03 | 2021-04-08 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-02-16 | 2021-03-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-16 | 2021-03-26 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-11 | Not Fixed | N |
