Menomonee Falls Health Services

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 resident was assessed to be clinically appropriate to self-administer medications.*R1 was observed with 6 medication pills in a medication cup on the over bed table next to R1 while R1 slept. R1 does not have a self-administration assessment completed identifying R1 was approved for self-administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 4 of 6 residents (R6, R1, R10, and R22) reviewed for accidents. * On 2/13/2025, a Certified Nursing Assistant (CNA) transferred R6 not according to R6’s plan of care and bumped R6’s leg. R6 required surgical intervention to R6’s right leg as a result of the CNA not following R6’s plan of care for transferring. * R1 had a fall on 4/11/2025 and no documentation was located that the facility did a thorough investigation. * R22 had a fall out of bed when staff did not follow R22’s plan of care. R22 was receiving cares with assist of one when R22 rolled out of bed. R22’s plan of care was to have assist of 2. * R10’s Wanderguard was incorrectly placed on R10’s wheelchair according to the manufacturer guidelines. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection. This has the potential to affect the 35 residents currently residing in the facility. * R22 has Stage 4 sacrum pressure injury. There was no EBP (enhanced barrier precaution) sign on or around R22's door and there was no PPE (personal protective equipment) cart observed outside R22's room. Staff was observed not wearing the appropriate PPE during personal cares. * R28 is on EBP. Staff was observed entering R28's room without appropriate PPE. * The facility experienced a COVID 19 outbreak starting on 11/12/24 until 12/3/24. There is no information as to residents and/or staff tested during this outbreak and no documentation as to type of isolation residents were placed in. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 5 Certified Nursing Assistants (CNA-S) received the required 12 hours of training per year. This has the potential to affect the total census of 35 residents.

Inspectors wroteBased on interview and record review, the facility did not ensure 8 (R2, R6, R3, R23, R4, R8, R22, and R28) of 9 residents were notified of the reason for transfer/discharge and bed hold policy in writing to the resident and their representative and the rate to reserve the resident bed was not documented in the facility’s transfer/ bed hold notice forms. * R2 was transferred to the hospital on 5/12/2025 and 7/23/2025, a transfer notice and bed hold rate was not provided in writing to R2 and/or R2’s representative. * R6 was transferred to the hospital on 2/13/2025, a transfer notice and bed hold rate was not provided in writing to R6 and/ or R6’s representative. * R3 was transferred to the hospital on 3/20/2025, 5/4/2025, and 5/14/2025, a transfer notice and bed hold rate was not provided in writing to R3 and/ or R3’s representative. [...]

Inspectors wroteBased on interview and record review the facility did not ensure MDS (minimum data set) assessments were coded correctly for 4 (R22, R28, R5, & R3) of 13 reviewed for MDS accuracy. R22's significant change MDS with an assessment reference date of 6/23/25 was incorrectly coded for PASRR (preadmission screening and resident review), pressure injuries, and insulin. R28's quarterly MDS with an assessment reference date of 6/13/25 was incorrectly coded for antibiotic. R5's Significant Change in Status Minimum Data Set (MDS) with an assessment reference date of 5/20/25, did not accurately reflect that R5 has current tobacco use and antipsychotic medication. R3's quarterly MDS with an assessment reference date of 7/2/25 was incorrectly coded for dialysis.

Inspectors wroteBased on record review and interview, the facility did not ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failing to conduct and maintain completed criminal background checks for 5 of 8 Certified Nursing Assistant (CNA) (CNA-S, CNA-T, CNA-U, LPN-V, and RN-W) facility staff reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R22 & R2) of 2 Residents reviewed for pressure injuries. *R22 was readmitted to the facility on [DATE] with a right buttocks & sacrum pressure injury. The facility did not comprehensively assess R22's right buttocks pressure injury on admission as there are no percentages of the wound bed listed in R22's admission assessment. R22's right buttock pressure injury was incorrectly staged on 6/17/25, 6/19/25, 6/27/25, & 7/3/25. On 6/27/25, R22's sacrum pressure injury was incorrectly staged as Stage 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medications were labeled or properly stored for 1 of 2 medication carts reviewed for medication storage. The facility did not ensure expired medications were properly removed from facility stock and individually prescribed medications. * R2 had medication stored in a medication cart with no date listed as to when medication had been opened*During the medication storage task, six vials of expired magnesium supplements were discovered in the facility's medication room and 1 vial of opened expired magnesium supplement was discovered in a medication cart.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident's hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for 1 (R5) of 2 residents reviewed for hospice services. Hospice visit notes were not updated in R5's medical record or in R5's hospice binder until Surveyor requested the information.

Inspectors wroteBased on staff interview and record review the Facility did not ensure 2 (R4 & R2) of 5 Resident reviewed were offered the influenza and/or pneumococcal immunization. R2 received the pneumococcal 23 on 5/18/12. R2's medical record does not have evidence R2 was offered and/or declined the pneumococcal vaccine 15, 20, or 21. R2's medical record does not have evidence R2 was offered and/or declined the influenza vaccine. R4's medical record does not have evidence R4 was offered and/or declined the Pneumococcal vaccine 15, 20, or 21.

Inspectors wroteBased on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R5, R4, and R2) of 5 residents reviewed for immunizations. * R5’s medical record does not contain any documentation as to whether R5 was offered, received, or declined the COVID-19 immunization. * R4’s medical record does not contain any documentation as to whether R4 was offered, received, or declined the COVID-19 immunization. *R2’s medical record does not contain any documentation as to whether R2 was offered, received, or declined the COVID-19 immunization.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure that residents with pressure injuries received the necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 of 2 residents (R5 and R7) reviewed. * R5, who was assessed to be at risk for pressure injuries, developed a stage 3 ischium pressure injury identified on 11/21/24. R5's care plan was not updated with new offloading interventions after the development of the ischium pressure injury. On 11/21/24, Wound Doctor (WD)-H recommended to upgrade offloading chair cushion. This was not completed by the facility. WD-H's treatment orders were not initiated until 11/26/24. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R5) of 7 residents reviewed were notified when there was a change in condition and a need to alter treatment. * R5's representative was not notified when R5 developed an open area below the left pinky toes on 11/5/24 and when R5 developed an area on the left outer ankle on 11/5/24. Findings Include: On 11/26/24, at 1:01 PM, Director of Nursing(DON) DON-B notified Surveyor there is no facility policy for notification. The facility's policy Pressure Injuries and Non pressure Injuries implemented 8/2/21 and last revised on 7/20/22 documents: .Resident/Responsible Party Education 1. Provide Residents/responsible parties education regarding risk of pressure injuries based on the overall Resident risk. 2. Inform Residents/responsible parties on the presence of wounds. 3. [...]

Inspectors wroteBased on observation, interview, and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 1(R5) of 4 residents reviewed. * R5's current physician orders, Certified Nursing Assistant (CNA) bedside [NAME], and comprehensive care plan document R5 is to wear size D double tubigrips to bilateral lower extremities (BLEs), worn toes to knees 23 hours/day as tolerated. Surveyor observed R5 to not be wearing the tubigrips during the survey process. On 11/14/24 an arterial open area was identified on R5's right 1st toe. R5's person-centered care plan was not updated with new interventions as well as R5 was not wearing physician ordered off-loading bilateral heel boots during the survey process. Findings Include: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure a resident (R) with hearing and vision impairment received proper treatment and assistive devices including arrangements for an audiology (ear doctor) for 1 (R5) of 1 residents reviewed for hearing and eyesight loss. * Surveyor observed R5 to not be wearing R5's glasses and bilateral hearing aides during the survey process. R5's Medication Administration Record(MAR) documented in August 2024, R5 had a referral for audiology consultation to evaluate need for or appropriate type of treatment relating to hearing deficits or medical problems. A consult was not completed. Findings Include: The facility's policy Use of Assistive Devices implemented 9/19/22 documents: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure medication administration records were complete and accurate for 2 (R1 and R3) of 5 residents reviewed for medication administration. * R1's Medication Administration Record (MAR) had empty signature boxes for multiple medications from 9/2024 through 11/2024. The signature boxes indicate the medication was administered by a nursing professional assigned to R1. * R3's MAR had empty signature boxes for multiple medications from 9/2024 through 11/2024. The signature boxes indicate if the medication was administered by a nursing professional assigned to R3.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and to ensure residents do not develop pressure injuries unless the individual's clinical condition demonstrates they were unavoidable; and residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (R5 and R26) of 2 residents reviewed for pressure injuries. R5 developed a facility acquired, stage 3, pressure injury. R26 developed a facility acquired stage 3 pressure injury on the coccyx on 4/4/24. This pressure injury was assessed on 4/5/24 as a Stage 2 pressure injury. [...]

Inspectors wrote2.) The facility policy entitled Smoking Policy revised 7/14/2022 states: To identify factors that may put residents at risk for smoking or nicotine use independently and to provide appropriate supervision/approaches for safety. This center shall establish and maintain a safe resident environment, while maintain resident rights, smoking or nicotine use will be limited to designated areas, supervision, and safety plans. Those residents who wish to engage in these practices will be educated, assessed, and provided with appropriate supervision to safely do so. Policy Explanation and Compliance Guidelines . 2. Risk factors identified through the assessment process shall be used in the development of the plan of care. 5. If a resident is deemed to be unsafe, they will be required to use a smoking apron, extender, or gloves and they may be required to smoke with supervision only. 9. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Residents expressed concerns to surveyors that the facility does not have sufficient staff, resulting in delayed call light responses. This deficient practice has the potential to affect all 30 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure food was stored or served in accordance with professional standards for food service safety potentially affecting all 30 residents residing in the facility. *During the initial tour Surveyor noted a jug of barbeque sauce sitting on the floor of the dry storage area, an open bag that had white powder in it that was unlabeled as to what it was, the freezer had an open bag of cheese omelets that was not dated, the lunch prep refrigerator had a container of several hot dogs sitting in liquid that was not dated or labeled, and a pitcher was not dated or labeled that was 1/3 full with brown liquid.

Inspectors wroteBased on observation, interview, and facility policy review the facility did not ensure the garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 30 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure they provided consistent staff on weekends to meet the resident needs for the 30 residents residing in the facility. During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered in the fiscal year quarter 1, 2023 (October-December) for low weekend staffing.

Inspectors wrote6. On 4/28/2024 at 12:21 PM Surveyor was observing staff and residents in the dining room. Surveyor observed certified nursing assistant (CNA)-M assisting a resident to eat. Surveyor observed CNA-M turn towards another resident and assist them to eat. Surveyor noted that CNA-M did not wash CNA-M's hands in between assisting the residents to eat. Surveyor observed the same routine throughout the noon meal and CNA-M not washing CNA-M's hands between residents when assisting them to eat. On 4/30/2024 at 4:02 PM Surveyor shared concerns with director of nursing (DON)-B regarding Surveyors observation of CNA-M not washing hands in between assisting two residents to eat. DON-B stated CNA-M should have washed CNA-M's hands or asked another staff member to assist the other resident to eat. No further information was provided. 5. [...]

Inspectors wroteBased on observation, and interview the facility did not provide a safe, clean, comfortable homelike environment which had the potential to affect all residents eating in the dining room and 2 (R282, R26) of 4 residents observed for cares. Surveyor observed residents being served meals placed in front of them on trays in the dining room. R282 had a strong urine odor in R282's bedroom and observations of yellow stains on the bed sheet on 4/29/2024 and 5/1/2024. Surveyor noted a urine odor and observed a yellow stain on the bed sheet for R26 when observing cares.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper code status documentation for 5 (R5, R10, R21, R23, and R26) of 5 residents reviewed for code status. R5's medical record indicated there was no form reviewed or signed by R5 indicating her code status wishes. R10's medical record indicated there was no form reviewed or signed by R10 indicating her code status wishes. R21's medical record indicated there was no Do Not Resuscitate (DNR) form signed by R21 indicating their code status wishes. R23's medical record did not have a code status order or indication of R23's wishes for resuscitation. R26's medical record indicated there was no DNR form reviewed or signed by R26 indicating their code status wishes.

Inspectors wroteBased upon interview and record review the facility did not ensure recommendations made through the medication regime review were addressed for 5 (R19, R25, R2, R4, and R7) of 30 sampled residents. *R19 had pharmacy recommendations on 11/9/2023, 12/8/2023, and 2/26/2024 to add a dose in grams for R19's order for Diclofenac sodium external gel 1%. The pharmacy recommendations were never followed up on. *R25 had pharmacy recommendations that were not followed up on. *R2 had pharmacy recommendations that were not followed up on. *R4 had pharmacy recommendations to decreased ferrous sulfate and complete an AIMS assessment that were never followed up on. *R7 had pharmacy recommendations that were not followed up on.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure that self administration of medications was determined to be clinically appropriate for 2 (R7 & R25) of 2 Residents. * On 4/28/24 a bottle of artificial tears eye drops and Fluticasone Propionate nasal spray was observed on R7's over bed table. R7 does not have a self administration of medications assessment or physician order to self administer medications. * R25 does his own perineum wound treatment without being assessed as being capable of doing the treatment himself. R25 does not have a self administration assessment or physician order.

Inspectors wroteBased on interview and record review, the facility did not ensure residents whose Medicare part A benefits ended, was provided with written beneficiary protection notifications for 1 (R7) of 3 residents sampled for beneficiary notifications. The facility did not provide R7 a written Advanced Beneficiary Notice (ABN), which includes financial liability information and appeal rights, at the time Medicare Part A coverage ended.

Inspectors wroteBased on record review and interview, the Facility did not notify residents and resident representatives of a transfer & the reasons for the transfer in writing to include the date, the location to which the resident is being transferred, a statement of the resident's appeal rights including the name, mailing and email address, and telephone number of the entity to which the appeal would be submitted, and information on how to obtain an appeal form, and the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman for 3 (R7, R21, and R5) of 3 residents reviewed for hospitalization. * R7 was hospitalized on [DATE] and no written transfer notice was provided to R7 and R7's representative. * R21 was hospitalized on [DATE] and no written transfer notice was provided to R21 and R21's representative. [...]

Inspectors wroteBased on record review and interview, the Facility did not notify residents and resident representatives of the duration of the bed-hold policy during which the resident was permitted to return to the facility and the reserve bed payment policy for 3 (R7, R21, and R5) of 3 residents reviewed for hospitalization. * R7 was hospitalized on [DATE] and no bed hold notice was provided to R7 and R7's representative. * R21 was hospitalized on [DATE] and no bed hold notice was provided to R21 and R21's representative. * R5 was hospitalized on [DATE], 4/1/24, & 4/5/24 and no bed hold notices were provided to R5 and R5's representative.

Inspectors wroteBased on interview and record review the Facility did not ensure 1 (R21) of 3 residents reviewed for Preadmission Screen and Resident Review (PASARR) had an updated level 1 screen or a level II referral when R21 was diagnosed with psychotic disorder with delusions on 6/26/23.

Inspectors wroteBased on interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 of 1 (R10) residents reviewed for ADL's (Activity of Daily Living). R10 did not consistently receive showers.

Inspectors wroteBased on observation, record, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds for 3 (R25, R19, and R26) of 13 sampled residents. *R19 does not have a comprehensive care plan in place for diuretic use or lymphedema treatments and monitoring for adverse reactions. R19's care plan and care [NAME] were not revised to R19's current treatment, and no orders for R19's treatment or interventions could be located. *R25 has a neoplasm on R25's perineal area that was not being assessed by nursing staff. *R26 has a venous stasis ulcer, treatments were not completed according to orders, there was no comprehensive assessment, and Surveyor had observations of R26's wound not being cleaned during wound treatment.

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents who enter the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 of 1 (R5) residents reviewed for catheters. R5 re-admitted to the facility following hospitalization with a Foley catheter. The facility did not follow up with urology or assess R5 for removal of the catheter.

Inspectors wroteBased on interview and record review the facility did not ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; for 2 of 5 (R5 and R21) residents reviewed for weights. R5 sustained severe weight loss. Neither the Dietician nor Physician was notified and no new interventions were implemented. R21 was not weighed weekly per Physician's orders.

Inspectors wroteBased on interview and record review the Facility did not comprehensively assess 1 (R2) of 1 Residents for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization.

Inspectors wroteBased on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 3 (R2, R26 & R17) of 5 Residents reviewed. * R2 receives Metoprolol Succinate ER 75 mg once a day. R2's heart rate was not being taken according to physician orders prior to receiving the medication. * R26 received Keflex 500 mg (milligrams), an antibiotic, once daily for 7 days starting on 2/6/24 without adequate signs/symptoms of UTI (urinary tract infection). * R17 receives Metoprolol Succinate ER 25 mg one time a day. R17's heart rate was not being taken according to physician orders prior to receiving the medication.

Inspectors wroteBased on observation, interview and record review the facility did not ensure medication error rates are not 5 percent or greater. The facility had a medication error rate of 21.05%. R17's Metoprolol Succinate ER (extended release) was crushed. R6's Amlodipine Besylate was held with no parameters to hold the medication. R20 did not receive Farxiga, Isosorbide Mononitrate ER, Metoprolol Succinate ER, Prozac and Spiriva inhaler as ordered. R28 did not receive Bumetanide as ordered.

Inspectors wroteBased on observation and record review, the facility did not ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, and include the expiration date when applicable for 1 of 2 medication carts reviewed. Insulin pens were not labeled, not dated when opened and were expired.

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure staff had successfully completed a State approved training course that meets the requirements before feeding residents for 1(R26) of 1 Residents. Life Enrichment Specialist-P was observed feeding breakfast to R26 on 4/29/24 & 4/30/24. Life Enrichment Specialist-P is not a CNA (Certified Nursing Assistant) and did not complete the State approved training course prior to feeding R26.

Inspectors wroteBased on record review and interviews, the facility did not ensure the facility had a hospice policy and procedure to designate a member of the Interdisciplinary team (IDT) to be responsible for communicating with hospice for coordination of care that has the potential to affect 4 of 4 residents receiving hospice services. * R8 and R26 were reviewed for receiving hospice services. When Surveyors asked to review the facility policy and procedures for hospice services, the facility stated there was not a policy and procedure for hospice services.

Inspectors wroteBased on staff interview and record review the Facility did not ensure 3 (R5, R332, & R26) of 5 Resident reviewed were offered the influenza and/or pneumococcal immunization. * R5's medical record does not contain any documentation as to whether R5 received or refused the influenza and pneumococcal immunizations. * R332's medical record does not contain any documentation as to whether R332 received or refused the influenza and pneumococcal immunizations. * R26's medical record does not contain any documentation as to whether R26 received or refused the pneumococcal immunization.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries, and with pressure injuries, were comprehensively assessed with an individualized plan of care. This was observed with 2 (R1, R2) of 3 residents reviewed with pressure injuries, and at risk for pressure injury. *R1 was assessed at high risk for pressure injuries. The facility did not initiate a turning or repositioning schedule for R1. On 10/10/23, R1 was noted with an unstageable necrotic pressure injury to their sacrum. The facility did not individualize R1's care plan related to their pressure injury or discuss risks versus benefits related to repositioning with R1 or R1's representative. *R2 was assessed at risk for pressure injuries. The facility did not ensure R2's pressure relieving interventions were in place in accordance with R2's comprehensive care plan.

Inspectors wroteBased on observation, record review and staff interviews, the facility did not always ensure that they provided foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 out of 1 (R2) residents reviewed with a diagnosis of Diabetes.

Inspectors wroteBased on document review, facility policy review, and staff interviews, it was determined that the facility failed to ensure 1 (Certified Nursing Assistant [CNA] L) of 24 facility staff members were fully vaccinated for COVID-19.