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4100 TREFFERT DR WINNEBAGO, WI 54985 | Government - State

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Health deficiencies are assigned during inspections that assess compliance with rules related to patient health and safety. Examples include violations of patients' rights and safety standards, as well as the administration of drugs and other treatments.

Life Safety deficiencies are assigned during inspections that assess a facility's compliance with National Fire Protection Association codes related to life safety in health care facilities. They are often conducted in tandem with health inspections. Examples include faulty or improperly maintained fire suppression and electrical systems.

Emergency Preparedness deficiencies can be cited during either a health or life safety inspection and relate to violations of CMS' Emergency Preparedness Rule. Examples include a lack of emergency plans, inadequate staff training and insufficient emergency supplies.

Complete reports and deficiency counts

Report date	Health Deficiencies	Life Safety	Emergency Preparedness	Total
Jul 13, 2022	3	0	0	3	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT PATIENT SAFETY
Jun 15, 2022	4	0	0	4	Read full report
Deficiencies cited in this report: STAFFING AND DELIVERY OF CARE RN SUPERVISION OF NURSING CARE CONTENT OF RECORD: ORDERS,NOTES,REPORTS PHARMACY: REPORTING ADVERSE EVENTS
May 5, 2022	3	0	0	3	Read full report
Deficiencies cited in this report: MEDICAL STAFF RESPONSIBILITIES - H&P MEDICAL RECORD SERVICES Discharge Summary
Jan 12, 2022	2	0	0	2	Read full report
Deficiencies cited in this report: INFECTION PREVENTION CONTROL ABX STEWARDSHIP INFECTION CONTROL PROGRAM
Nov 17, 2021	3	0	0	3	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION
Oct 27, 2021	3	0	0	3	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION PATIENT RIGHTS: RESTRAINT OR SECLUSION
Apr 27, 2021	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT
Jan 5, 2021	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION
Oct 27, 2020	2	0	0	2	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING
Jul 30, 2020	4	0	0	4	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: INFORMED CONSENT RN SUPERVISION OF NURSING CARE Social Service Records Discharge Summary
Nov 12, 2019	1	0	0	1	Read full report
Deficiencies cited in this report: DISCHARGE PLANNING EVALUATION
Oct 16, 2018	2	0	0	2	Read full report
Deficiencies cited in this report: COMPLIANCE WITH 489.24 RECIPIENT HOSPITAL RESPONSIBILITIES
Aug 29, 2018 Follow-up to inspection on 2018-02-28*	15	0	0	15	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING DATA COLLECTION & ANALYSIS STAFFING AND DELIVERY OF CARE NURSING CARE PLAN CONTENT OF RECORD COMPETENT DIETARY STAFF THERAPEUTIC DIET MANUAL INFECTION CONTROL PROGRAM IMPLEMENTATION OF A DISCHARGE PLAN REASSESSMENT OF A DISCHARGE PLAN REASSESSMENT OF DISCHARGE PLANNING PROCESS EVALUATION ESTIMATES INTELLECTUAL/MEMORY FUNCTIONING EVALUATION INCLUDES INVENTORY OF ASSETS PLAN INCLUDES SPECIFIC TREATMENT MODALITIES UTILIZED
Jun 27, 2018 Follow-up to inspection on 2018-02-28*	14	0	0	14	Read full report
Deficiencies cited in this report: QAPI COMPETENT DIETARY STAFF PHYSICAL ENVIRONMENT LIFE SAFETY FROM FIRE REASSESSMENT OF DISCHARGE PLANNING PROCESS SPECIAL MEDICAL RECORD REQUIREMENTS EVALUATION ESTIMATES INTELLECTUAL/MEMORY FUNCTIONING EVALUATION INCLUDES INVENTORY OF ASSETS PLAN INCLUDES SPECIFIC TREATMENT MODALITIES UTILIZED TREATMENT DOCUMENTED TO ASSURE ACTIVE THERAPEUTIC EFFORTS SPECIAL STAFF REQUIREMENTS FOR PSYCHIATRIC HOSPITALS MONITOR/EVALUATE QUALITY/APPROPRIATENESS OF SERVICES PARTICIPATES IN FORMULATION OF TREATMENT PLANS ADEQUATE STAFF TO PROVIDE NECESSARY NURSING CARE
Jun 27, 2018 Follow-up to inspection on 2018-02-28*	0	5	0	5	Read full report
Deficiencies cited in this report: Multiple Occupancies Doors with Self-Closing Devices Hazardous Areas - Enclosure Sprinkler System - Installation Subdivision of Building Spaces - Smoke Barrie
Feb 28, 2018	25	0	0	25	Read full report
Deficiencies cited in this report: PATIENT RIGHTS PATIENT RIGHTS: CARE IN SAFE SETTING DATA COLLECTION & ANALYSIS STAFFING AND DELIVERY OF CARE NURSING CARE PLAN CONTENT OF RECORD COMPETENT DIETARY STAFF THERAPEUTIC DIET MANUAL PHYSICAL ENVIRONMENT LIFE SAFETY FROM FIRE INFECTION CONTROL PROGRAM IMPLEMENTATION OF A DISCHARGE PLAN REASSESSMENT OF A DISCHARGE PLAN REASSESSMENT OF DISCHARGE PLANNING PROCESS SPECIAL MEDICAL RECORD REQUIREMENTS EVALUATION ESTIMATES INTELLECTUAL/MEMORY FUNCTIONING EVALUATION INCLUDES INVENTORY OF ASSETS PLAN BASED ON INVENTORY OF STRENGTHS/DISABILITIES PLAN INCLUDES SHORT TERM/LONG RANGE GOALS PLAN INCLUDES SPECIFIC TREATMENT MODALITIES UTILIZED TREATMENT DOCUMENTED TO ASSURE ACTIVE THERAPEUTIC EFFORTS SPECIAL STAFF REQUIREMENTS FOR PSYCHIATRIC HOSPITALS MONITOR/EVALUATE QUALITY/APPROPRIATENESS OF SERVICES PARTICIPATES IN FORMULATION OF TREATMENT PLANS ADEQUATE STAFF TO PROVIDE NECESSARY NURSING CARE
Feb 28, 2018	0	22	0	22	Read full report
Deficiencies cited in this report: Multiple Occupancies Doors with Self-Closing Devices Vertical Openings - Enclosure Hazardous Areas - Enclosure Hazardous Areas - Enclosure Fire Alarm System - Installation Fire Alarm System - Testing and Maintenance Fire Alarm System - Testing and Maintenance Fire Alarm System - Testing and Maintenance Sprinkler System - Installation Sprinkler System - Installation Sprinkler System - Maintenance and Testing Sprinkler System - Maintenance and Testing Portable Fire Extinguishers Portable Fire Extinguishers Portable Fire Extinguishers Portable Fire Extinguishers Corridor - Doors Subdivision of Building Spaces - Smoke Barrie Portable Space Heaters Construction, Repair, and Improvement Operati Electrical Equipment - Power Cords and Extens
Dec 13, 2017	9	0	0	9	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: CARE IN SAFE SETTING PATIENT RIGHTS: RESTRAINT OR SECLUSION MEDICAL STAFF MEDICAL STAFF PERIODIC APPRAISALS MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY NURSING CARE PLAN PATIENT CARE ASSIGNMENTS CONTENT OF RECORD REASSESSMENT OF A DISCHARGE PLAN
Jun 12, 2015	1	0	0	1	Read full report
Deficiencies cited in this report: PATIENT RIGHTS: RESTRAINT OR SECLUSION
Jun 8, 2015	3	0	0	3	Read full report
Deficiencies cited in this report: CONTENT OF RECORD: FINAL DIAGNOSIS DOCUMENTATION OF EVALUATION REASSESSMENT OF DISCHARGE PLANNING PROCESS
Nov 9, 2011	1	0	0	1	Read full report
Deficiencies cited in this report: MAINTENANCE OF PHYSICAL PLANT

Some state health departments and regional offices of the Centers for Medicare and Medicaid Services sometimes did not upload their inspection reports into a central computer system that could then be shared by us. In such cases, CMS identified the dates of the missing inspections and the number of deficiencies identified. You can request the actual reports from CMS or your state health department.

* Deficiencies cited in follow-up inspections are not counted toward a facility's total deficiency count.

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WINNEBAGO MENTAL HEALTH INSTITUTE

Complete reports and deficiency counts