A Sun Prairie assisted living facility where a resident was found dead outside in the cold late last year has been cited with four new violations, involving a resident who fell and died and false documentation of residents at risk of escaping.
Faith Gardens failed to have appropriate plans for use of fall alarms for two residents, including one who fell on Dec. 9 and died after being taken to a hospital, according to inspection reports from the state Department of Health Services.
The resident who died after falling wasn’t wearing a fall alarm because a family member removed it and forgot to reattach it, the records say. The facility administrator said staff should have reattached the alarm, but the incident happened shortly after the family member left.
Another resident who fell had a large bruise under the right eye, and an inspection found the facility did not have a correct plan for using a fall alarm.
In addition, staff “pre-filled” logs recording the location of three residents at risk of leaving the facility, which a Faith Gardens administrator acknowledged was “false documentation,” state inspectors said.
At 7 a.m., the logs already said the residents were in their rooms at 8 a.m. and in the dining area at 9 a.m.
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The four new citations, and a $650 fine, are in addition to four citations and a $4,200 fine the facility received in January.
The earlier sanctions came after Alice McGaw, 84, who had dementia, was found dead outside on the morning of Dec. 29, when the temperature was below 10 degrees. Hypothermia was a likely contributor, officials said.
In January, the state also told the facility to stop taking new residents. The order was lifted in February after the state said the violations were corrected and Faith Gardens paid $2,730, a 35 percent discount that is routine for payments within 10 days.
The new violations stem from follow-up inspections Feb. 22 and March 20, along with a new complaint and a self-report by the facility.
In the McGaw incident, the state said Faith Gardens failed to use a front-door alarm, left an inside door propped open and didn’t check often enough on McGaw, who had frequently tried to leave the facility.
McGaw’s family told inspectors that they transferred her in October to Faith Gardens, which can have up to 17 residents, after she rolled her wheelchair out the door of another, larger, assisted living facility and was almost hit by a car.