Complete Care at Care Age

In the surveyor’s words

From the most serious findings on record at Complete Care at Care Age, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 25, 2025

  Based on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) after experiencing a change of condition for 1 of 11 residents reviewed (R20). R20 had an unintended sudden change of plane while being transferred by a sit to stand lift by a lone Certified Nursing Assistant (CNA). While in the lift sling, the lift's battery died, and resident ended up in a squatting position with her buttocks touching the foot pads of the lift. This sudden change of plane resulted in a hip fracture. […]

• Immediate jeopardy, isolatedF760May 27, 2021

  Based on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed (R1) was free of significant medication errors. On 3/5/21 Licensed Practical Nurse (LPN)-C was completing medication pass in front of R1's room when she was distracted by therapy staff requesting pain medications for a resident prior to treatment. LPN-C stepped aside to administer the pain medications. Upon return to the medication pass the cart was outside R1's room; however, the medication electronic medical record (EMR) on the screen was for R5. LPN-C proceeded to prepare R5's medications and presented them to R1 who took the medications. […]

• Actual harm, isolatedF686Jun 25, 2025

  Example 2 R35 was admitted to the facility 4/24/23 with diagnoses including, but not limited to, the following: Dementia (a group of thinking and social symptoms that interferes with daily functioning), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar), abnormal gait (walking different than normal), chronic kidney disease (disease of the kidneys that will eventually lead to kidney failure), and hypertension (high blood pressure). On 4/24/23, the facility's Treatment Administration Record (TAR) documents the following: Monitor feet to ensure skin is intact and free from s/sx (signs/symptoms) of developing skin alterations. Notify MD (Medical Doctor) with any change in skin integrity. Every evening shift for prevention of skin impairment. […]

• Actual harm, isolatedF689Jun 25, 2025

  Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 1 of 2 residents (R20) reviewed for falls resulting in actual harm, 1 of 1 resident (R31) reviewed for motorized wheelchair charging, and 2 of 4 units reviewed for lithium battery charging. R20 is being cited at Actual Harm/Isolated. R31 and 2 of 4 units is being cited at Potential for Harm/Isolated. R20 was care planned to be a two person assist with a sit to stand transfer. CNA L transferred R20 alone when the lift lost battery power. R20 ended up sitting on the ground, had a sudden drop from the lift, and a change of plane/fall. […]

• Actual harm, isolatedF686Jan 5, 2023

  Based on observations, record review and staff interviews, the facility did not always ensure that 3 out of 4 residents ( R37, R2, R360) reviewed for pressure ulcers received the necessary care and treatment to promote healing of existing pressure ulcers and to avoid the development of new pressure ulcers. R37 developed a Stage #3 pressure ulcer to his middle finger of the right hand. R37's range of motion to the right hand had deteriorated and a contracture developed. R37 was not provided with pressure relief for the contracture to the right hand and developed the stage #3 pressure ulcer. R2 had a history of resolved pressure ulcers to the right ankle and left buttocks. […]