Inspection Reports for Ascension Living Alexian Village – Milwaukee

The complaint investigation was triggered by concerns that the facility did not promptly resolve a resident's grievance about incontinence care, failed to complete required PASARR screenings after a 30-day exemption expired, inadequately investigated multiple falls of a high-risk resident, and did not address significant weight loss in a resident with no physician or dietician notification.

The facility failed to ensure prompt resolution of resident grievances, did not complete timely PASARR screenings for mental disorders, inadequately investigated resident falls, and did not properly monitor or address significant weight loss in a resident. Deficiencies were noted in grievance handling, mental health screening, fall prevention and investigation, and nutritional care.

The complaint involved a resident (R2) reporting inappropriate touching by another resident (R1). The facility delayed reporting the incident to the Nursing Home Administrator by at least twelve hours. Interviews revealed staff confusion about reporting procedures. Additionally, the facility failed to notify the psychiatric provider or the resident's Power of Attorney about R1's behaviors and did not provide medically related social services after the incident.

The facility failed to report an allegation of abuse in a timely manner, with a delay of at least twelve hours in notifying the Nursing Home Administrator. Additionally, the facility did not ensure that a resident exhibiting inappropriate behaviors received necessary psychiatric care or that the resident's Power of Attorney was contacted for consent. Both deficiencies were found to have minimal harm or potential for actual harm affecting a few residents.

The complaint investigation involved multiple residents (R2, R3, R5, R7, R9, R10, R11, R12, R13, R16, R17) and staff members including CNA1 and RN1. Substantiated findings included verbal abuse by CNA1 and drug diversion by RN1. The facility failed to notify representatives, protect residents from abuse, prevent property misappropriation, and timely report and investigate incidents.

The facility was found to have multiple deficiencies including failure to notify resident representatives of falls, failure to protect residents from verbal and potential sexual abuse, misappropriation of resident property and narcotic drug diversion by staff, failure to timely report suspected abuse and neglect to the State Survey Agency, and incomplete investigations of abuse allegations.

The complaint investigation focused on the facility's failure to report a resident's missing necklace within 24 hours and the inadequate investigation of a resident's fall where the resident was found under a fallen dresser. The investigation revealed delays in reporting and incomplete fall investigation.

The facility failed to report a resident's missing gold necklace to the Nursing Home Administrator within 24 hours and delayed the investigation. Additionally, the facility did not thoroughly investigate a resident's fall, focusing primarily on whether a dresser fell on the resident rather than the root cause of the fall or ensuring all dressers were safely secured.

The complaint investigation involved allegations of abuse, neglect, failure to report abuse timely, inadequate investigation of abuse and falls, incomplete PASARR screening, inadequate care planning, failure to prevent pressure injuries, inadequate fall prevention, nutritional monitoring failures, respiratory care deficiencies, infection control lapses, and food safety violations affecting multiple residents including R5, R111, R45, R4, R52, R48, R55, R57, R38, R29, R43, R24, R44, and R60.

The facility failed to timely report abuse allegations, thoroughly investigate abuse and falls, provide comprehensive care plans for residents' needs including incontinence and pressure injuries, ensure PASARR screenings were completed accurately, maintain nutritional status monitoring, provide appropriate respiratory care, maintain infection control practices, and ensure food safety standards. Multiple residents were affected by these deficiencies.

The complaint investigation revealed that the facility did not timely report abuse allegations involving residents R45, R5, and R111 to the State Survey Agency or law enforcement. The abuse investigations were incomplete, with limited staff interviews and no review of camera footage. Resident R45 reported being held down and changed against his will, resulting in shoulder pain and a suspected rotator cuff tear. The facility allowed a CNA accused of possible retaliation to continue working during the investigation. Falls involving residents R38, R29, and R43 were not thoroughly investigated, and fall prevention interventions were not consistently implemented or updated in care plans.

The facility failed to timely report and thoroughly investigate multiple abuse allegations involving residents R45, R5, and R111. The investigation of abuse allegations was incomplete, with selective staff interviews and lack of evidence review. Additionally, the facility did not ensure adequate supervision and fall prevention interventions for residents R38, R29, and R43, resulting in multiple falls and injuries without proper root cause analysis or care plan updates.

The complaint investigation included allegations of privacy breaches, delayed reporting of abuse, inadequate investigations of abuse and neglect, failure to provide appropriate care, incomplete medical records, failure to offer COVID-19 immunizations, and lack of staff training.

The facility failed to ensure privacy and confidentiality of resident information, timely reporting and thorough investigation of abuse allegations, proper treatment and care according to professional standards, complete and accurate medical records, and adequate staff training in multiple required areas including infection control, resident rights, abuse prevention, communication, and compliance.

The complaint investigation focused on an incident where resident R1 fell and required CPR. RN-D, an agency nurse, left the resident to retrieve the AED despite the resident still having a pulse and respirations, and did not have an up-to-date CPR certification. Multiple staff interviews revealed lack of clear delegation and communication during the emergency. The facility did not have a formal written process for Code Blue events, and agency staff CPR certifications were not consistently verified.

The facility lacked a system to ensure staff response during CPR events and did not maintain records verifying agency staff CPR qualifications. An incident involving resident R1 revealed that RN-D, an agency nurse, did not have current CPR certification at the time of the event, and staff were not properly coordinated during the emergency response.

The complaint investigation revealed multiple deficiencies including failure to notify providers of significant weight loss, lack of written transfer and bed hold notices, inadequate monitoring of antipsychotic medication adverse reactions, unsecured medication carts, and improper infection control practices.

The facility was found deficient in notifying providers of significant weight loss for one resident, providing written transfer and bed hold notices for three residents, monitoring adverse reactions to antipsychotic medication for one resident, securing medication carts properly, and implementing proper infection prevention and control practices during resident care.

The investigation was complaint-related, focusing on the substantiated issue that the resident's air mattress was not moved with her to a new room for about 8 days, leading to a decline in her sacral pressure injury. Facility staff did not recognize the wound deterioration until identified by the Nurse Practitioner on 11/3/22.

The facility failed to ensure that resident R1 received necessary treatment for a stage 4 pressure injury, resulting in a significant decline in the wound after the resident was moved to a new room without the ordered air mattress for approximately 8 days. Facility staff did not recognize the wound deterioration despite daily dressing changes, and documentation falsely indicated compliance with air mattress use.

The complaint investigation found that the facility did not monitor or change the dressing of a resident's dialysis port as required, and the Infection Preventionist lacked required specialized training. The resident confirmed that dressing changes were only done at the dialysis clinic, not the facility.

The facility failed to ensure that a resident's dialysis port was monitored and assessed for complications as required by professional standards, and the designated Infection Preventionist had not completed specialized infection control training, potentially affecting all residents.