Complete Care at Hales Corners

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580May 19, 2021

  Based on interview and record review the facility did not ensure the physician was immediately consulted with and provided all relevant information for one 1 (R1) of 4 residents reviewed when R1 experienced a significant change in the resident's physical, mental or psychosocial status. * R1 had a fall with a head injury on 1/17/21. The facility contacted R1's physician via text message and waited 4 hours for a response. The facility did not inform the physician R1 experienced a change in mentation at the time of the fall. Three and a half hours after the fall R1 experienced increased head pain rating the pain as 9 out of 10 on a pain scale. R1's physician was not notified of the increased head pain following a head injury. […]

• Actual harm, isolatedF686Mar 27, 2024

  Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice to prevent pressure ulcers from developing for 2 (R43 and R19) of 3 residents reviewed for pressure injuries. *R43 was admitted to the facility with an Unstageable pressure injury to the right elbow that required antibiotics for a wound infection and developed pressure injuries to the left heel and right Achilles. Wound documentation was not an accurate description of staging, measurements, and characteristics of the wound. *R19 was admitted to the facility with a Stage 3 pressure injury to the right outer ankle. […]

• No harm, potential for more than minimal, widespreadF803Jan 12, 2023

  Based on observations and record review, the facility failed to ensure the facility developed and followed the menus and that the menus met the nutritional needs of the residents. This failure placed all 38 facility residents at risk of nutritional problems and dissatisfaction with their meals. Findings include: Review of the facility's 01/09/23 to 01/13/23 weekly menu, provided on paper by Dietary Manager (DM) E, revealed it did not include extensions for therapeutic diets or portion sizes. The weekly menu documented the 01/11/23 lunch menu for the following for Wednesday: -Chicken noodle soup or yogurt and fruit plate -Corndog -Potato chips -Peppermint cake There were no alternatives listed for therapeutic diets, such as Mechanical Soft, and there were no portion sizes listed. […]

• No harm, potential for more than minimal, widespreadF886Jan 12, 2023

  Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to implement staff COVID-19 testing in the presence of a COVID-19 outbreak in the facility. This failure affected all 134 who worked in the facility and all 38 residents. This failure had the potential to contribute to spread of COVID-19 within the facility. Findings include: Review of the facility's policy titled, Testing for COVID-19 in Residents and Employees dated 09/28/22, documented All employees will be tested for CO\/ID-19 if there is an outbreak, defined as one case. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2021

  Based on observation, staff interviews, and record review the facility did not ensure food was stored in a safe and sanitary manner which had the potential to affect all 38 residents at the facility. Foods in refrigerators and coolers were not labeled and dated per food safe practices and/or were expired or beyond use-by dates. Findings include: On [DATE] at 9:45 AM, Surveyor began initial kitchen tour with DM (Dietary Manager)-C. During the tour, Surveyor and DM-C entered the cooler located in the kitchen. Surveyor observed food items within the cooler including: -6 bottles of [NAME] Choice yellow mustard, 2# 8oz size. Received date marked as [DATE] and best by date of [DATE]. -1 4# 4oz container of Fruit Blendz pear puree with a received dated of [DATE]. […]