Newcare

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 31, 2023

  Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R28) of 1 resident received adequate supervision to prevent elopement. R28 was admitted to the facility on [DATE] and assessed to be at risk for elopement. R28 had diagnoses of schizophrenia and mild cognitive impairment. R28 wore a wanderguard, but was allowed to sit outside the front of the building while supervised by staff inside the building. On 10/10/22, R28 was observed by a Dietary Manager still on facility grounds, but beyond the adjacent Assisted Living facility. On 11/2/22, R28 was observed walking down the driveway toward the road. On 11/7/22, R28 was found at an apartment complex three blocks from the facility. […]

• Actual harm, isolatedF689May 19, 2021

  Based on observation, record review and interview, the facility did not ensure that 1 Resident (R) (R235) of 4 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent accidents. R235 admitted to the facility on [DATE]. Admission assessments indicated R235 was at-risk for falls. Despite being at-risk for falls, fall prevention interventions were not incorporated into R235's baseline plan of care upon admission. R235 subsequently fell on [DATE] and sustained a fracture to the right hip. Findings include: On 5/17/21, Surveyor reviewed the medical record for R235. […]

• No harm, potential for more than minimal, widespreadF812May 31, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 41 residents residing in the facility. The facility did not monitor and document dishwashing wash cycle temperatures. Staff did not test Quaternary sanitizing solution per manufacturer's instructions. Cook (CK)-E did not wash hands after performing tasks that contaminated CK-E's hands. Food cooking appliances (ovens, toaster, steam table) and kitchen food prep areas were not cleaned and sanitized. Findings include: During an initial tour of the kitchen on 5/15/23 at 8:05 AM, Dietary Manager (DM)-D informed Surveyor the facility followed the Wisconsin Food Code for dietary services. […]

• No harm, potential for more than minimal, widespreadF868May 19, 2021

  Based on staff interview and record review, the facility did not ensure Quality Assessment and Assurance (QAA) committee met quarterly with the Medical Director (MD)-K for 3 out of 4 quarterly meeting attendance records reviewed. This had the potential to effect all 29 residents at the facility. The facility did not ensure MD-K participated in quarterly QAA meetings held on 4/16/20, 7/16/20, and 12/17/20. Findings include: On 5/17/21, during entrance conference beginning at 8:57 AM, Nursing Home Administrator (NHA)-A disclosed that facility QAA meetings held quarterly did not include MD-K in person, telephonically, or via video call. […]

• No harm, potential for more than minimal, patternF656Aug 20, 2025

  Based on observation, staff and resident interview, and record review, the facility did not develop and/or implement an individualized, comprehensive care plan for 4 residents (R) (R11, R16, R6, and R13) of 14 sampled residents. R11 smoked and received oxygen therapy. R11 also received diuretic medication and was on contact and droplet precautions. The facility did not develop a comprehensive care plan that included interventions related to smoking, the use of diuretic medication, or infection prevention precautions. R16 smoked and received oxygen therapy. The facility did not develop a comprehensive care plan that included interventions related to smoking. […]