A list of the most recent deficiencies for Minocqua Health 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-24 | 2023-12-21 | 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 | 2023-12-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-24 | 2023-12-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-24 | 2023-12-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-24 | 2023-12-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-24 | 2023-12-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-24 | 2023-12-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-24 | 2023-12-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-10-25 | 2023-11-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-25 | 2023-11-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-25 | 2023-11-25 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-25 | 2023-11-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-25 | 2023-11-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-25 | 2023-11-25 | 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 | 2023-10-25 | 2023-11-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-25 | 2023-11-25 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-10-25 | 2023-11-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-25 | 2023-11-25 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-10-25 | 2023-11-25 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-13 | 2023-07-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-13 | 2023-07-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-13 | 2023-07-13 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-01-30 | 2023-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-05 | 2023-01-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-05 | 2023-01-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-05 | 2023-01-30 | N |
| Use approved construction type or materials. | Fire Safety | 2022-10-05 | 2022-11-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-05 | 2022-11-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-05 | 2022-11-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-10-05 | 2022-11-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-05 | 2022-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-05 | 2022-11-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | 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 | 2022-10-05 | 2022-11-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-05 | 2022-11-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-16 | 2022-09-09 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-08-16 | 2022-09-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-16 | 2022-09-09 | 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 | 2022-08-16 | 2022-09-09 | 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 | 2022-08-16 | 2022-09-09 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-08-16 | 2022-09-09 | 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 | 2022-08-16 | 2022-09-09 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-16 | 2022-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-27 | 2022-09-09 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-07-27 | 2022-09-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-27 | 2022-09-09 | 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 | 2022-07-27 | 2022-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-09 | 2022-09-09 | 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 | 2022-06-09 | 2022-09-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-01 | 2022-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-10 | 2022-09-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-10 | 2022-09-09 | 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 | 2022-05-10 | 2022-09-09 | 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 | 2022-05-10 | 2022-09-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-09 | 2022-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-09 | 2022-07-12 | 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 | 2022-06-09 | 2022-07-12 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-06-01 | 2022-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-01 | 2022-07-12 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-01 | 2022-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-01 | 2022-07-12 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-01 | 2022-07-12 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-01 | 2022-07-12 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-05-10 | 2022-07-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-10 | 2022-07-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-10 | 2022-07-12 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-05-10 | 2022-07-12 | 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 | 2022-05-10 | 2022-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-10 | 2022-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-10 | 2022-07-12 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-10 | 2022-07-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-10 | 2022-07-12 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-05-10 | 2022-07-12 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-05-10 | 2022-07-12 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-10 | 2022-07-12 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-05-10 | 2022-07-12 | 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 | 2022-05-10 | 2022-07-12 | 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 | 2022-05-10 | 2022-07-12 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-05-10 | 2022-07-12 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-10 | 2022-07-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-09 | 2022-04-25 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-03-09 | 2022-04-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | 2022-04-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-09 | 2022-04-08 | 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 | 2022-03-09 | 2022-04-08 | Y |
| Help the resident with transportation to and from laboratory services outside of the facility. | Health | 2022-03-09 | 2022-04-08 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-09 | 2022-04-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-15 | 2022-03-17 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-15 | 2022-03-17 | 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 | 2021-12-20 | 2022-03-10 | 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 | 2022-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-20 | 2022-01-30 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-11-03 | 2021-12-10 | 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 | 2021-12-10 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-30 | 2021-08-30 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-09 | 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 | 2021-06-09 | 2021-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-09 | 2021-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-09 | 2021-08-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-09 | 2021-08-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-14 | 2021-08-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-14 | 2021-08-23 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-07-14 | 2021-08-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-14 | 2021-08-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-14 | 2021-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-14 | 2021-08-23 | 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 | 2021-07-14 | 2021-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-14 | 2021-08-23 | 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 | 2021-07-14 | 2021-08-23 | 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 | 2021-07-14 | 2021-08-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-14 | 2021-08-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-14 | 2021-08-23 | 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 | 2021-07-14 | 2021-08-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-14 | 2021-08-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-14 | 2021-08-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-14 | 2021-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-14 | 2021-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-14 | 2021-08-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-14 | 2021-08-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-14 | 2021-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-14 | 2021-08-23 | Y |
| Post nurse staffing information every day. | Health | 2021-06-14 | 2021-08-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-14 | Not Fixed | N |
