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Deficiency Records for Ccc of Pewaukee
A list of the most recent deficiencies for Ccc of Pewaukee. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Ccc of Pewaukee. 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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-08-20 | 2024-09-13 | 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 | 2024-08-20 | 2024-09-13 | 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 | 2024-08-20 | 2024-09-13 | 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 | 2024-08-20 | 2024-09-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-20 | 2024-09-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-08-20 | 2024-09-13 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-03-05 | 2024-04-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-05 | 2024-04-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-05 | 2024-03-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-05 | 2024-03-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-05 | 2024-03-26 | 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 | 2024-03-05 | 2024-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-04 | 2024-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-04 | 2024-03-26 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-03-04 | 2024-03-26 | 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 | 2024-03-04 | 2024-03-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-04 | 2024-03-26 | 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 | 2024-03-04 | 2024-03-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-04 | 2024-03-26 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-03-04 | 2024-03-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-04 | 2024-03-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-04 | 2024-03-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-04 | 2024-03-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-04 | 2024-03-26 | N |
| 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 | 2024-03-04 | 2024-03-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-03-05 | 2024-03-12 | 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 | 2023-12-26 | 2024-01-15 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-12-26 | 2024-01-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-26 | 2024-01-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-12-26 | 2024-01-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-26 | 2024-01-15 | 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 | 2023-12-26 | 2024-01-15 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-21 | 2023-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-21 | 2023-12-01 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-29 | 2022-12-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-29 | 2022-12-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-11-29 | 2022-12-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-29 | 2022-12-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-29 | 2022-12-28 | 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 | 2022-11-29 | 2022-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2022-12-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-01 | 2022-12-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-01 | 2022-12-28 | N |
| Respond appropriately to all alleged violations. | Health | 2022-12-27 | 2022-12-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-27 | 2022-12-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-27 | 2022-12-28 | 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 | 2022-12-01 | 2022-12-28 | 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 | 2022-12-01 | 2022-12-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-01 | 2022-12-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2022-12-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-01 | 2022-12-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-14 | 2022-11-09 | 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 | 2022-10-14 | 2022-11-09 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-08-09 | 2021-09-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-08-12 | 2021-09-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-12 | 2021-09-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-12 | 2021-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-12 | 2021-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-09 | 2021-09-07 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-09 | 2021-09-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-09 | 2021-09-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-09 | 2021-09-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-09 | 2021-09-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-09 | 2021-09-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-08-09 | 2021-09-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-09 | 2021-09-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-09 | 2021-08-30 | 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 | 2021-08-09 | 2021-08-30 | N |
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