Both the Centers for Medicare and Medicaid Services (CMS) and the state of Wisconsin conduct routine investigations, inspections and surveys at every nursing facility statewide. These inspections help to identify serious concerns, health violations, and deficiencies that harm or could cause harm to residents. When problems are detected, the facility is provided the opportunity to make necessary adjustments to their policies and procedures and improvements to the level of care they provide.
In serious cases, the regulators might designate the Home as a Special Focus Facility (SFF). This undesirable designation also includes placement on the Federal Medicare deficiency watch list where the nursing home must undergo additional and unscheduled surveys and inspections. If the facility cannot or will not make improvements, they may lose their ability to provide care to Medicaid/Medicare-funded patients.
In 2017, federal regulators designated CHI Franciscan Villa as a Special Focus Facility. Likely, the nursing home will remain on the watch list for many years to come until regulators are assured that all improvements made to the benefit of resident care are permanent. Some concerns, deficiencies, and violations involving this facility are detailed below.
This Long-Term Care Center is a ‘not for profit’ 150-certified bed Home providing cares to residents of South Milwaukee and Milwaukee County, Wisconsin. The Facility is located at:
3601 S Chicago Ave
South Milwaukee, WI 53172
(414) 764-4100
In addition to providing skilled nursing care, the Center also offers rehabilitation services including:
The state of Wisconsin and the federal government had the legal authority to impose monetary penalties on any nursing facility identified as having serious concerns, violations and deficiencies. Posting the payment of a fine online help alert the public that there are serious problems at the nursing home that must be addressed.
Over the last three years, CHI Franciscan Villa received four separate monetary penalties including a $6,370 fine on 03/05/2015, a $41,438 fine on 03/03/2016, an $82,388 fine on 06/13/2016, and a fine of $113,232 on 04/04/2017. On June 13, 2016, Medicare denied the facility a request for payment due to substandard care. During the last 36 months, regulators investigated 11 formally filed complaints and seven facility-reported issues that all resulted in citations.
Families can review publically available data concerning every long-term and intermediate care facility in Wisconsin by visiting numerous state and federal government databases including the Medicare.com website. The site offers details on incident inquiries, safety concerns, health violations, dangerous hazards, filed complaints and opened investigations. Reviewing this data can a valuable tool to use when choosing the best location to place a loved one who needs the highest level of services and care in a safe environment.
Currently, CHI Franciscan Villa maintains an overall two out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, four out of five stars for staffing issues, and four out of five stars for quality measures. Some deficiencies, safety concerns, and health violations involving this facility include:
In a summary statement of deficiencies dated April 4, 2017, the state investigator documented that the facility “did not immediately consult with [a resident’s] Physician when there was a change in the resident’s physical condition.” The surveyor noted that the resident “experienced a change of condition when he was exhibiting symptoms of a stroke, which included verbalizing the inability to move his left side, and experienced numbness and tingling on his left side. The facility did not complete a thorough assessment and did not report the new lap-sided weakness, numbness, and tingling to the physician.”
The surveyor noted that this deficiency while providing treatment to the resident who “experience a stroke and was unable to receive treatment due to a delay in hospitalization” led to “a decline in the [movement] of his left arm and leg. The facility’s failure to notify the physician when the resident reported symptoms of a possible stroke created a finding of Immediate Jeopardy.”
The facility was reminded to follow the American Medical Director’s Association, Stroke Management and Long-Term Care Settings Clinical Practice Guideline that reads in part:
“Early identification and treatment can help to decrease stroke-related disability and death for appropriately selected patients. For this reason, the signs of acute stroke must be recognized and addressed promptly.
Common presentations of an acute stroke include sudden confusion, difficulty speaking, or difficulty understanding speech sudden difficulty walking, severe dizziness or a loss of balance or coordination.
Sudden numbness or weakness of the face or in the arm or leg, especially if confined to one side of the body. Sudden severe headaches with no other readily identifiable cause.”
In a summary statement of deficiencies dated June 8, 2017, the state investigator documented that the facility “did not ensure that [two residents] received adequate supervision and assistive devices to prevent an accident during Hoyer lift transfers.” One incident involved a resident who “fell forward, hitting her head on the short swinging bar of the Hoyer lift. No injury was noted. The facility ‘re-inserviced’ the two Certified Nursing Assistants involve but did not provide training to other nursing assistants because the facility was conducting ongoing skills validation.”
In a separate summary statement of deficiencies dated September 21, 2017, the state surveyor documented that the facility “did not ensure [three residents] at risk for falls received necessary interventions, adequate supervision, or necessary services to prevent falls.” One incident involved a resident who “had five falls without injury with one of the falls having no interventions put into place, and one fall with an intervention put into place (bowel and bladder assessment) was not completed. There was no …cause analysis for the five falls.”
In a third summary statement of deficiencies dated January 5, 2016, the state investigator documented that the facility “did not ensure that each resident receives adequate supervision and an assistive device to prevent accidents.” The deficient action by the nursing staff involved one resident “reviewed who requires a mechanical lift for transfers.”
The incident occurred on November 16, 2015, while the resident “was being assisted with a transfer from a Brody chair to her bed. During the transfer, while the resident was suspended above the Brody chair, the swivel arm of the lift (the part of the lift where the sling attaches to the lift) broke off the arm of the lift. The resident fell back into the wheelchair, and the swivel arm landed on the resident’s chest.
After the lift malfunction, the facility did not evaluate or analyze how the mechanical lift malfunctioned and did not implement interventions to reduce the risk of recurrence. The nursing staff did not thoroughly communicate to maintenance staff [any] information about the broken lift, including resident specific information.”
In a fourth summary statement of deficiencies dated March 3, 2016, the investigator documented that the facility “did not always ensure that [a resident] at risk for falls, or have experienced falls, had fall prevention measures in place.” Documented evidence reveals that the resident “had a fall [before their] nursing home admission, and a fall out of bed since [their] nursing home admission. Following the fall of the nursing home, measures to prevent future falls were determined in the Care Plan was revised.” However, “new measures of body pills for fall preventions were not found to be in place at the time of the survey.
In a summary statement of deficiencies dated January 5, 2016, the state investigator documented the facility “did not provide sufficient staff to meet the resident’s needs on the second shift of November 11, 2015. The facility did not have sufficient staff to provide one-on-one staff ratio for one resident who was identified as requiring one-on-one supervision.”
The state investigator interviewed the Director Nursing who indicated that it is the “facility’s policy for one-on-one staff to resident ratio means the staff person is to be with that resident only.” The Director indicated that “a one to one staff to resident ratio was initiated for [that resident] upon the resident’s return from the hospital.” The investigator reviewed the facility’s Policy and Procedure for Suicide Precautions dated November 25, 2003, that read in part:
“The policy indicates that the resident’s [attempted] suicide, the facility should provide continuous supervision in a public area or one-on-one supervision.”
The surveyor documented that the night shift on November 11, 2015 “the facility did not have sufficient staff to maintain one-on-one staff supervision for the resident who had exhibited [potential suicide].”
In a summary statement of deficiencies dated September 21, 2017, the state investigator documented that the facility “did not ensure that each resident’s drug regimen is free from unnecessary drugs.”
One incident involved a review of a resident’s medical records revealing the resident received antibiotics to treat urinary tract infections. However, documents revealed that the resident “did not show signs and symptoms of a urinary tract infection. There was no evidence that the facility spoke with [the resident’s] physician or nurse practitioner to ask if the antibiotic should be continued after he returned from the hospital.”
The facility did notify the “resident’s physician the following day to notify him that the resident did not meet McGeer’s Criteria of Infection and is without fever or symptoms of a urinary tract infection.” The resident’s physician acknowledged that the resident “did not meet the criteria but wanted the antibiotic continued. The facility failed to notify the Medical Director related to the continued use of an antibiotic without the resident meeting the McGeer’s Definition of Infection.”
In a summary statement of deficiencies dated March 3, 2016, the state investigator identified failures. One deficiency involved a failure when the facility “did not ensure that one resident [reviewed to be] at risk for pressure ulcers received the necessary care and services to promote the healing of pressure ulcers that were present and prevent the development of additional pressure ulcers.” Also, the “facility failed to conduct a risk assessment as identified in the Plan of Care and update the Plan of Care to reflect approaches to minimize risk factors.”
The state investigator documented that the facility “failed to recognize a deep tissue injury [DTI] another skin breakdown located on the coccyx/sacral area of pressure ulcers. Instead, these areas were addressed as non-pressure and abraded areas and documentation and not initially followed by the Wound Certified Nurse or Wound Team.”
Documentation that reveals that on “December 21, 2015, the Wound Certified Registered Nurse (WCC) examined the resident and did not address the skin breakdown areas to the residents left heel side blister, buttocks or coccyx (tailbone) areas of skin alteration. The right heel blister is addressed as a non-pressure area.” However, “on December 23, 2015, the abraded area to the coccyx/sacrum was determined to have gotten bigger with changes to the wound bed and foul older. No action was taken at this time by the physician, the Wound Nurse, or the wound team.”
The investigator stated that “on December 27, 2015, the skin alteration to the buttocks and tailbone area continue to show signs of deterioration. There was no assessment of this [change] by the physician, Wound Nurse, or wound team, and no treatment changes put in place to address the wound bed now having yellow slough.”
Documentation revealed that “the facility took the corrective action on January 27, 2016, when the issue became an allegation of neglect, evaluated the situation and identified internal needs for correction. The facility plan of action was put into place and in Immediate Jeopardy was removed, and the deficiency corrected on February 1, 2016.” However, the investigator cited the incident as “past non-compliance.”
In a separate summary statement of deficiencies dated June 13, 2016, the state surveyor noted that the facility “did not consult with the resident’s physician when indicated. The resident’s physician was not consulted multiple times when the resident’s pressure injury presented with an odor, which could signify the development of an infection and resulted in deterioration of the pressure injury.”
This incident involved a resident admitted to the facility from an assisted living facility or rehabilitation center “without any pressure injuries.” Soon afterward, “a ruptured blister was observed on the residents left heel when the [dressing] was removed.”
It was determined that the resident had an “unstageable pressure ulcer measuring 4.6 x 7.6 cm with no odor.” However, five days later, the injury scab “appeared to be coming off, and the treatment was not done. The facility did not consult with the physician that the treatment was not done.” It was also documented that the facility “staff called the physician but did not speak with the physician. There was no follow-up with consulting with the physician” even when the resident’s “pressure injury presented with an odor.”
If you believe your grandparent, parent or spouse died prematurely or suffered serious injury while a patient at CHI Franciscan Villa, contacting a personal injury attorney can help. A lawyer working on your behalf can handle every aspect of your case including filing a claim, presenting evidence of court, or negotiating a settlement.
A personal injury attorney will provide immediate legal representation without any upfront payment or fee. All legal fees are paid only after the law firm has successfully resolved your case in a court of law or by negotiating with the defendant’s attorneys or insurance carrier.
Sources:
Attorney Gerald Bekkerman
Licensed in Wisconsin
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home