Milwaukee Health and Rehab

In the surveyor’s words

From the most serious findings on record at Milwaukee Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF678Jan 23, 2023

  Based on interview and record review, the Facility did not ensure staff provided basic life support to 1 (R15) of 3 Residents who required Cardiopulmonary Resuscitation (CPR.) The facility currently has 49 out of 62 residents who desire CPR (Full Code.) The failure of staff to immediately call a code for R15 on the over head page system, the failure to not start CPR immediately, the failure to have the required supplies on the crash cart, and the failure of the facility to ensure there was an AED (Automated External Defibrillator) when an AED had been used in a code a month earlier created a finding of immediate jeopardy that began on [DATE]. Administrator-A, DON (Director of Nursing)-B, & Nurse Consultant-C were notified of the immediate jeopardy on [DATE] at 4:30 p.m. […]

• Immediate jeopardy, patternF835Nov 14, 2022

  Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (R2 & R1) reviewed with a history and/or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . * The facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when the facility did not follow their facility assessment by screening R1 for behavioral issues prior to admission, did not develop a person centered care plan for behavioral and suicide attempts, and did not train staff on… […]

• Immediate jeopardy, isolatedF741Nov 14, 2022

  Based on observation, record review, and interview, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and related services to assure resident safety and for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (R) reviewed (R1 and R2) who have a history and/or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *R2 leaped from a second story window after experiencing delusions and hallucinations. Prior to this, R2 had been on 15 minute checks for wandering in/out of other Resident rooms, and was not on behavioral monitoring for being on [MEDICATION(S)], an anti-psychotic, or for the wandering behavior. […]

• Immediate jeopardy, isolatedF600Sep 1, 2022

  Based on interview and record review, the facility did not ensure 1 (R5) of 1 Resident reviewed was free from physical abuse. On [DATE], R6, who was assessed as being at moderate risk for aggressive behavior, physically assaulted his roommate, R5. The injuries R5 sustained were serious and required sutures before surgery (to repair a left side periorbital fracture) could be scheduled. The facility did not do a Preadmission Screen Annual Resident Review (PASARR) level 2 screen on admission despite R6's psychiatric diagnoses, did not address a previous incident when he was physically aggressive towards a certified nursing assistant (CNA), did not implement a care plan to address R6's behavior triggers with person centered approaches, and did not implement a behavior monitoring system that… […]

• Immediate jeopardy, isolatedF745Sep 1, 2022

  Based on interview and record review, the facility did not ensure 1 (R12) of 5 Residents reviewed received medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. R12 demonstrated hypersexuality behavior upon admission. The facility failed to assess R12's sexualized behaviors to thoroughly understand R12's ability to consent. The facility did not develop and implement psychosocial interventions to address R12's pattern of sexual activity based on assessments and behavior demonstrated in the facility, thus limiting R12's ability to exercise her Resident Rights. […]