Clinically Deficiency Free Survey 2011

Jul 21, 2011 | What's New


Nursing homes in Wisconsin operate under rules enacted by the Federal government (for
the Medicare and/or Medicaid programs) and by the State of Wisconsin. Surveyors from
the Wisconsin Division of Quality Assurance conduct unannounced inspections at each
nursing home at least once every 9 to 15 months to determine if the nursing home
complies with all State and Federal rules. State surveyors also conduct follow-up visits
to ensure that violations have been corrected, investigate complaints, and conduct other
surveys as necessary.
When state surveyors determine that a nursing home is not in compliance with a Federal
regulation, the nursing home is cited with a violation or “deficiency”. The number and
type of violations for surveys conducted in 2010 are described in this report.
The number of federal regulation deficiencies cited in Wisconsin nursing homes during
2010 surveys ranged from 0 to 77, with an average of 7.2 cites.
Federal Regulation Deficiencies:
To determine Federal regulation deficiencies, surveyors use a resident-centered,
outcome-based process. Equal emphasis is placed on the quality of care the resident
receives and on the quality of the resident’s life in the nursing home, and on whether or
nor the resident’s rights, dignity and privacy are respected. These factors are evaluated by
observing residents’ care; interviewing residents, families and staff; and reviewing
medical records.
If it is determined that a Federal regulation deficiency exists, the deficiency is placed on a
grid. Grid placement is based on two measures:
• Severity/Harm, the degree of impact that a deficient practice has
on residents at the facility; and
• Scope/Frequency, the prevalence of a deficient practice within a
facility, or the proportion of residents who were or could have
been affected.
All Federal deficiencies fit into one of the following four grid levels, from most to least
serious: Immediate Jeopardy, Significant Correction, Correction and Substantial
Compliance. If this home had deficiencies at any of the four grid levels in the last
survey, those deficiencies are listed below. Each deficiency listed is followed by the
abbreviation of its federal regulation category: Quality of Care (QC), Resident Services
(RS), Quality of Life (QL), Resident Rights (RR), Freedom from Restraints/Abuse
(FRA), and Other Violations (OT). A deficiency may be listed more than once if it
was cited more than once during the year. Also, some cites share the same title, so
you may see separate cites listed with the same title on the same date.
Certain Federal regulation deficiencies at the Immediate Jeopardy, Significant Correction
and Correction grid levels cause a nursing home to be designated as having “Substandard
Quality of Care (SQC)”. This home was not designated with SQC during the year
2010. Fifty-five Wisconsin homes received the SQC designation in 2010.
deficiencies constitute: immediate jeopardy to resident health or safety; a pattern of or
widespread actual harm that is not immediate jeopardy; or widespread potential for more
than minimal harm that is not immediate jeopardy, with no actual harm.
Immediate Jeopardy. This deficiency exists when a situation caused (or is likely to
cause) serious injury, serious harm, impairment or death to a resident receiving care in
the facility AND facility practice makes it probable that similar actions, situations,
practices, or incidents will occur again. Immediate corrective action is needed. The
nursing home received 0 Immediate Jeopardy deficiencies in 2010.

Significant Correction. This deficiency exists when a situation resulted in a
negative.outcome that compromised a resident’s ability to maintain or reach his/her
highest practicable physical, mental, or psychosocial well-being. This nursing home
received 0 Significant Correction deficiencies in 2010.

Correction. This deficiency exists when a situation resulted in minimal physical,
mental, or psychosocial discomfort to a resident and/or has the potential (not yet realized)
to compromise a resident’s ability to maintain or reach his/her highest practicable
physical, mental, or psychosocial well-being. This nursing home received 0 Correction
deficiencies in 2010.

Substantial Compliance. This deficiency exists when a situation has the potential for
causing only minor negative impact on residents. This nursing home received 0
Substantial Compliance deficiencies in 2010.

For questions about this report, call (608)267-7230. For further information about
violations or more recent surveys, contact the administrator of this facility or the
Division of Quality Assurance (608)266-8368