State orders Kenosha nursing home into compliance after resident death

KENOSHA, Wis. — The Wisconsin Department of Health Services has barred a Kenosha senior living center from taking in new residents until it complies with health and safety standards.

The state’s Division of Quality Assurance investigated Parkside Manor Assisted Living and Memory Care following the death of an 89-year-old resident on Dec 19.

According to police, she was found outside the facility and died from exposure to the cold. Neither police nor Parkside Manor has identified the woman.

The state’s investigation found that the woman had been admitted to Parkside with dementia, although upon initial assessment of her health, she did not exhibit “behavioural issues” or “wander.”

However, she began to wander and eventually attempted to exit the facility several times, according to the investigation. None of those interventions or a need to increase their level of supervision were noted in their individualized service plan, the investigation shows.

At around 12:40 am on the morning the woman died, the state said she left the facility into the secured courtyard but “staff did not provide 30-minute checks during the night.” Temperatures were below freezing — as low as 8 degrees Fahrenheit — the entire time she was outside.

According to the report, she was only discovered missing over six hours later, when the day shift conducted resident checks.

Kenosha police said that staff did not follow policy and conduct a head count after an exit door alarm was triggered, the state’s investigation reported. According to police, caregivers also confirmed that they did not open the door to check for residents after the alarm.

According to an order from the health department, Parkside Manor must immediately comply with health and safety standards that cover behavior management and door alarms.

The senior living facility has 45 days to come into compliance with other orders, including a review of each resident, a revision of their individualized service plans, and assurances that all staff has reviewed residents’ individual plans.

The state has determined Parkside’s Licensee, Encore Wisconsin LLC, must forfeit $1,900 for code and administrative violations. By not appealing, that fine is reduced to $1,235.

The company has a right to appeal within ten days of receiving the orders.

TMJ4’S Bruce Harrison reached out to Parkside Manor for comment on the release of the state’s investigation. They responded with a statement they issued last month:

“We are heartbroken by the tragic loss of one of our residents. Our deepest sympathy goes out to their family and friends. While we cannot discuss specifics or details, we are conducting a thorough investigation. We remain committed to serving seniors in a comfortable community where their care needs, happiness, and well-being are prioritized. We continuously strive to deliver the highest quality care in a homelike environment to our residents.”

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