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A 95-year-old woman died after a morphine overdose last year at Capitol Lakes Health Center in Downtown Madison.

A 75-year-old woman fell 26 times before breaking her pelvis in 2010 at Nazareth Health and Rehabilitation Center in Stoughton.

A woman was found outside, shaking from the cold and rain, after falling out of her wheelchair in 2009 at Karmenta Center on Madison's East Side.

Regulators fined the nursing homes and gave them immediate jeopardy citations, the most serious available. The facilities are among five nursing homes in Dane County — the others are Oak Park and Sunny Hill in Madison — that had a total of nine immediate jeopardy violations over the past three years, a Wisconsin State Journal review of state records found.

Nursing home inspection reports detailing such incidents, which have not been easily accessible to the public, will be posted online beginning this summer, state officials say.

It's one of several changes affecting the state's long-term care industry, which is growing in importance as the population ages. State laws passed last year capped malpractice awards against nursing homes and eliminated state fines when federal fines are imposed for the same problem.

Nursing homes now are urging the state to boost financial incentives to replace aging, institutional facilities with home-like environments thought to improve care and quality of life.

Reports to be posted online

The five nursing homes in Dane County with immediate jeopardy citations from 2009 to 2011 were fined a total of $137,781 for the violations, according to state and federal records.

The county has 21 of Wisconsin's 399 nursing homes, or 5.3 percent. The county's nine immediate jeopardy citations made up 3.9 percent of 231 such citations statewide the past three years.

Reports detailing immediate jeopardy and other violations will be put online starting in July as part of the 2010 federal health reform law, said Otis Woods, administrator of the state Department of Health Services' Division of Quality Assurance.

Only new reports, issued roughly once a year for each facility, will be posted, Woods said. Previous reports can be requested under open records laws, and nursing homes are required to post their two most recent reports in their facilities.

Citations are only one factor to consider when evaluating nursing homes, authorities say. Others include staffing levels, cleanliness, flexibility of daily schedules and attitudes of residents and family members.

But immediate jeopardy citations, the most serious of four categories of citations, can be viewed as red flags. "Once you see immediate harm, jeopardy, your antenna should go up: What happened?" Woods said.

Immediate jeopardy citations

Several of Dane County's immediate jeopardy citations involved falls or lack of prompt reporting of changes in residents' medical conditions.

A summary:

Capitol Lakes: A 95-year-old woman received 10 times too much morphine on April 15, 2011, and died the next day. The nursing home was fined $4,550 by the federal government and $6,300 by the state.

Capitol Lakes, which has 98 beds, said it started giving morphine in pre-filled syringes after the incident to prevent such errors. In an unsuccessful appeal, the nursing home said the resident "was end-stage and in the dying process, so there was not harm to her receiving more pain medications."

Tim Conroy, executive director of Capitol Lakes, said in an interview with the State Journal: "She was going to die. This is not what killed her."

Nazareth: A 75-year-old woman fell 26 times from June 2009 until March 19, 2010, when she broke her pelvis. The nursing home was fined $2,730 by the federal government and $1,869 by the state.

Inspectors said Nazareth, which has 99 beds, used several measures to try to prevent the woman from falling, including special socks, motion sensors, alarms, belts, cushions, frequent room checks and anti-tip brakes on her wheelchair.

After the citation, the facility said a sitter would remain with the resident around the clock while further plans were developed.

Scott Arneson, administrator of Nazareth since December, said in an interview that a falls prevention team, which previously met once or twice a week, started meeting daily after the citation.

"There's a fine line between freedoms and restraints, between protecting somebody and giving them the freedom to walk," Arneson said.

Karmenta: A woman was found face down, bruised and "shaking uncontrollably" in a courtyard after falling out of her wheelchair on March 9, 2009, inspectors said. She had been outside for three hours on a rainy day with temperatures in the high 30s.

The nursing home was fined $4,908 by the federal government and $4,344 by the state.

Karmenta, which has 105 beds, said after the incident it would lock the doors at 8 p.m. instead of 10 p.m., and the patient agreed to use an "in-out" sign to tell staff when she was outside.

On Aug. 18, 2010, Karmenta had two more immediate jeopardy violations involving two patients whose medical changes weren't properly cared for or reported, inspectors said.

A 68-year-old man had a dangerously high blood thinner ratio, a dangerously low potassium level and rapid weight gain.

Another resident had rapid weight gain that exacerbated his heart failure and "could have led to his death."

The nursing home was fined $10,238 by the federal government and $21,304 by the state.

"Karmenta Center engages in continuous quality improvement efforts," the nursing home said in a statement to the State Journal.

Oak Park: The nursing home had three immediate jeopardy violations on Feb. 19, 2009, involving residents who were dehydrated or whose medical changes weren't properly cared for or reported, inspectors said.

A 63-year-old woman wasn't given enough fluids when she became severely dehydrated and lost 10 pounds in two weeks. Another patient also wasn't treated appropriately for dehydration. A resident on chemotherapy had a "critically low" white blood cell count, but she wasn't isolated to prevent infection and her doctor wasn't promptly notified, inspectors said.

The nursing home, which has 100 beds, was fined $50,700 by the federal government and $17,550 by the state.

Jim Raab, interim administrator at Oak Park and therapy director at the time of the citations, said in an interview that staff left a message for the chemotherapy resident's doctor but failed to follow up after the doctor didn't call back.

After the citations, staff started checking every resident daily for dehydration, not just residents considered susceptible, Raab said.

Sunny Hill: One resident fell 10 times and another fell 15 times, and the nursing home didn't properly respond, inspectors found on Feb. 4, 2009.

The nursing home, which has 68 beds, was fined $4,100 by the federal government and $9,188 by the state.

"Sunny Hill updated resident care plans, re-educated staff on care plans and fall prevention and increased quality review efforts," administrator Clayton Nieman said in a statement to the State Journal.

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