State extends ban on Reflections at Moraine Ridge new residents following DHS report

The state says the facility continues to violate regulations
Published: May. 25, 2023 at 10:38 PM CDT
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GREEN BAY, Wis. (WBAY) - Green Bay senior living facility Reflections at Moraine Ridge hasn’t had a new resident since July of 2022, and they won’t for the foreseeable future.

In its first report, the Wisconsin Department of Health Services (DHS) put in place an order at Reflections at Moraine Ridge to not admit any new or additional residents because of violations found.

The report wanted the facility to address issues related to health monitoring, and inadequate and unqualified caregivers.

On April 11, a 90-page violation report shows the order has been extended after the Department of Health Services found another 20 violations.

Three of the 20 highlighted concerns and violations include undocumented injuries to patients, not administering required medication, and unqualified caregivers.

The DHS report shows two residents at Reflections at Moraine Ridge died from unexplained injuries that were not investigated internally by the facility and could have contributed to each of their passings.

The first resident was found on the floor after a fall, was then diagnosed with a fractured hip, and died on November 6, 2022.

The hospice nurse for that resident called the resident’s family member who holds power of attorney to let the family know the resident was dying. The hospice nurse then left the facility and the power of attorney “went looking” for staff to monitor. The report claims the caregiver in charge that night was unaware of the resident’s changing condition and the hospice nurse never notified her.

The second resident died from multiple injuries of “unknown origin” following multiple falls that no one saw. Staff noticed bruises on November 9, 2022, on the resident’s right hand and arm. Three days later, staffers noticed new bruising. Hospice staffers were called in and told caregivers to start giving the resident pain medication. The resident died on November 21, 2022.

In an interview with DHS, a caregiver said: “No, there was no investigation, no one talked to us caregivers...{Administrator A} is never here...the other administrators have officials over there {the sister facility on campus} they are rarely ever here... they don’t care about these residents here...they’re just interested in that new facility they just opened...nobody looked into it.”

Administrators told DHS they didn’t know they were supposed to document or report unknown injuries on residents’ injuries.

The state found that Reflections of Moraine Ridge was also in violation of skipping or not administering proper medication to residents.

One documented incident details how Resident Two, who passed November 21, 2022, was prescribed morphine and lorazepam every four hours, but during the night shift, there was no one on staff who was trained to administer the medication. A morning caregiver said she had to “play catch up” with the pain medications.

“Resident 2 had end-of-life medications in the building,” one caregiver said in an interview with DHS. “They had super bad anxiety...Resident 2 was not given their morphine and it was even scheduled! There wasn’t anyone here at night that could give it to them. You can call over there {the sister facility on campus} but they don’t always come to help. I had to play catch up because they were in pain.”

The report stated, “Trained staff were not continuously available to supervise residents when caregivers were occupied”.

Action 2 News reached out to Inspired Senior Healthcare, which runs Reflections at Moraine Ridge. President and CEO Michael Klein sent us the following statement:

“Reflections at Moraine Ridge is dedicated to providing quality care to its residents. As a facility with a strong compliance history, we disagree with the findings and conclusions of the department, as well as the actions of the department. We have chosen to pursue an appeal and, consequently, are unable to provide further comment at this time.”