EASTCASTLE PL BRADFORD TER CONV CTR
Non profit - Corporation
40 Beds
Independent
Data: November 2025
Trust Grade
70/100
#31 of 321 in WI
Photo by Eastcastle Place
Photo by Eastcastle Place
Photo by Eastcastle Place
1 / 10 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Eastcastle Place Bradford Terrace Convalescent Center has a Trust Grade of B, indicating a good reputation and solid choice among nursing homes. They rank #31 out of 321 facilities in Wisconsin, placing them in the top half, and #3 out of 32 in Milwaukee County, meaning only two local options are better. The facility is improving, with reported issues decreasing from 2 in 2024 to 1 in 2025. Staffing is a strength, rated 5 out of 5 stars, though staff turnover is average at 51%, slightly above the state average of 47%. However, the facility has concerning fines of $99,452, which are higher than 91% of Wisconsin facilities, indicating potential compliance issues. While they have above-average RN coverage, there are some significant weaknesses. For instance, one resident was not given adequate treatment to prevent a pressure injury, which was eventually misclassified, risking their health. Additionally, there were concerns regarding COVID-19 testing protocols for staff who had vaccination exemptions, affecting potential exposure for all residents. Lastly, there was a lack of proper assessments and documentation for repositioning devices for multiple residents, highlighting areas that need improvement. Overall, while there are strengths in staffing and care quality, families should be aware of the compliance issues and specific incidents that could impact care.
- Trust Score
- B
- In Wisconsin
- #31/321
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $99,452 in fines. Lower than most Wisconsin facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 60 minutes of Registered Nurse (RN) attention daily — more than 97% of Wisconsin nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 9%
Needs review
2 → 1 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2024: 2 issues
2025: 1 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 51%
Near Wisconsin avg (46%)
Higher turnover may affect care consistency
Federal Fines: $99,452
Well above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 17 deficiencies on record
1 actual harm
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R1) of 1 facility reported incidents reviewed for an allega...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R1) of 1 facility reported incidents reviewed for an allegation of misappropriation, was reported to the local law enforcement agency.*On 6/26/25, facility staff was made aware of R1's missing narcotic pain medication. The facility did not report the incident to local law enforcement.Findings include: The facility policy with a revision date of November 2022, titled Controlled Substances documents, in part: . Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. The director of nursing services documents irreconcilable discrepancies in a report to the administrator. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. The administrator, consultant pharmacist and/or director of nursing services determine whether other action(s) are needed, e.g., notification of police or other enforcement personnel. The facility policy dated 9/22/23 titled Abuse Prevention Program documents, in part: . Employees are required to report any incident, allegation, or suspicion of potential abuse neglect or misappropriation of property they observe, hear about, or suspect immediately to the Administrator or the person in charge of the community, acting on behalf of the Administrator. If a crime is suspected, the Administrator will coordinate timely reporting to the state survey agency and local law enforcement on behalf of the employees involved. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. If a reasonable suspicion of a crime has occurred, the resident's representative and the Department of Health and law enforcement shall be informed according to the following timeframes: Serious bodily injury- immediately but not later than 2 hours after forming the suspicion. All others- not later than 2 hours after forming the suspicion.R1 was admitted to the facility on [DATE]. R1 is currently on hospice care and has the following active MD order: Morphine Sulfate (Concentrate) Oral Solution 100 [milligrams (mg) per 5 milliliters (ml)]. Give 0.25 ml by mouth every 4 hours as needed for Pain - Moderate to severe pain.Surveyor reviewed the facility self-report regarding R1's Morphine medication. The self-report documents, in part: During narcotic count PM shift change on June 26, 2025, our two-nurse counting protocol identified an isolated discrepancy with [R1]'s morphine syringe bags. The two nurses counting were present. The physical count did not align with the documented record, resulting in a numerical variance from 19 vs. 20 syringes. Investigation initiated, and a comprehensive search of the designated medication storage and transport areas was performed. Nurse Educator contacted all relevant nursing staff who had been on duty since the discrepancy was identified. [R1] is on hospice services, who were also spoken to and did not administer. Pharmacy also contacted and confirmed that the 20 syringes were delivered on the refill on 6/25. The investigation concluded that there was no evidence of diversion or intentional misappropriation as the singular 0.25morphine syringe was not found through investigation and search. The self-report includes: all staff interviews and statements completed, the conclusion of the audits of medication carts, the pharmacy packing slip indicating the amount of Morphine delivered on 6/25/25, review of R1's Medication Administration record, Narcotic sheets and pain assessments, and Education provided to nursing staff. On 7/15/25 at 12:51 PM, Surveyor interviewed Registered Nurse (RN)-E who worked the night shift starting on 6/25/25 and went to the morning of 6/26/25. Surveyor asked what occurred on 6/25/25 through 6/26/25 regarding R1's Morphine medication. RN-E stated that on the evening of 6/25/25 RN-E received a delivery of R1's Morphine from the pharmacy. RN-E stated that RN-E took the bag of Morphine and counted the number of syringes twice to ensure the count was correct. RN-E stated that Licensed Practical Nurse (LPN)-C was witness to the count completed. RN-E stated there was 20 syringes. RN-E put the medication in the med drawer and locked the drawer. RN-E did not give any Morphine during that shift. RN-E stated that R1 was comfortable and did not display any signs or symptoms of pain during that shift. At the end of RN-E's shift, RN-E completed the narcotic count with LPN-D and the count remained at 20 syringes.On 7/15/25 at 12:46 PM, Surveyor interviewed LPN-C who worked the PM shift on 6/25/25 and the PM shift on 6/26/25. Surveyor asked what occurred on 6/25/25 through 6/26/25 regarding R1's Morphine medication. LPN-C stated that LPN-C witnessed the counting of R1's Morphine on 6/25/25 after it was delivered by pharmacy. LPN-C stated that RN-E counted the medication and got a count of 20. The next day when LPN-C returned to the facility for LPN-C's next shift, LPN-C completed the count of R1's Morphine with LPN-D, the count was 19. LPN-C stated that LPN-C reviewed the Medication Administration Record and Narcotic sheet, and nothing was documented that R1 received the Morphine. LPN-C stated that LPN-C immediately reported the missing narcotic medication to nursing leadership.On 7/15/25 at 12:03 PM, Surveyor interviewed LPN-D who worked the Day shift when the facility found that R1's Morphine syringe was missing. LPN-D indicated that LPN-D is very careful about counting narcotic pain medications. LPN-D indicated that when LPN-D started the shift on 6/26/25, the count of morphine was 20, at the end of LPN-D's shift, the count was 19. LPN-D stated that R1 was comfortable and did not require any Morphine during the shift. When the discrepancy was identified, nursing leadership was notified.On 7/15/25 at 1:32 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated that DON-B was made aware of the Morphine discrepancy by Assistant Director of Nursing (ADON) when DON-B was on vacation. When DON-B returned to the facility after vacation, DON-B reviewed the on-going investigation and wanted to continue to investigate to find out what happened. DON-B stated that in addition to all of what is included in the investigation, DON-B, the ADON and the nurse educator, took the time to sit and watch all video camera footage of when R1's Medication was delivered to the facility until the count was completed and a syringe was missing. DON-B stated that nothing concerning was found on the video footage. DON-B stated that the facility was unable to identify the cause of R1's missing Morphine.Surveyor concluded that despite not knowing what caused the count to be off, the facility did complete a thorough investigation into R1's missing Morphine syringe. Surveyor noted the facility did not contact local law enforcement to inform them of the misappropriation of R1's Morphine medication.On 7/15/25 at 12:40 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor asked if local law enforcement was notified of the misappropriation of R1's Morphine medication. NHA-A stated that contacting the police was discussed with the facility consultant, but the police were not notified. NHA-A indicated that they did not feel like this was a systemic issue as there was only one syringe missing. NHA-A stated that at one point, facility staff thought they had solved the discrepancy but that was not the case. Given that it was not a systemic issue the police were not notified. NHA-A asked Surveyor if the police should have been called. Surveyor stated that if there is reasonable suspicion of a crime, police should be notified. NHA-A stated that's on me. NHA-A indicated NHA-A did not suspect a crime because it was just one dose but did appreciate the feedback. Surveyor informed NHA-A of the concern that police were not notified after the misappropriation of R1's Morphine medication.No further information was provided.
Nov 2024
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not ensure the call light was within reach for 1 (R290) of 12 residents revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not ensure the call light was within reach for 1 (R290) of 12 residents reviewed.
*R290 was observed in R290's room without a call light within reach.
Findings include:
R290 was admitted to the facility on [DATE]. R290's BIMS score is 13 as documented in a progress note, on 11/13/2024 at 01:55 PM.
R290's care plan documents in part, R290 has Activities of Daily Living (ADL) self-care performance deficit, related to activity intolerance, and anemia. R290 is completely dependent on staff assistance for bathing, dressing, toileting; and requires an assist of 2 staff, using a Hoyer lift for transfers. R290's care plan indicates R290 is at risk for falls, with an intervention documenting, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Surveyor notes R290's care plan does not indicate R290 prefers to call for assistance using the cordless phone, or that R290's call light does not have to be within reach.
A progress note, dated 11/14/2024, at 11:46 AM, documents in part, R290 will be admitted to the Facility for long term care, R290 is able to makes needs known, R290 uses a Hoyer lift at baseline and is reliant on staff to meet Activities of Daily Living (ADL) needs.
On 11/25/2024, at 12:23 PM, Surveyor observed R290 up in wheelchair, the bedside table was within reach, and the call light was attached to R290's bed, which was out of reach for R290. R290 indicated to Surveyor that the call light is normally attached to R290. Surveyor asked R290 how R290 would call for assistance. R290 informed Surveyor that R290 would need to yell.
On 11/25/2024, at 01:27 PM, R290 informed Surveyor that R290 used R290's cordless phone to call down to the front desk around 12:50 PM, to ask for assistance being put into bed due to R290's buttock was painful. R290 informed Surveyor that a staff member came in and moved R290's bedside table containing the cordless phone, out of R290's reach, then left R290's room. R290 asked Surveyor to move R290's side table back over by R290 so that R290 can attempt to call for assistance again. Surveyor noted R290 was unable to move around the room without assistance.
On 11/25/2024, at 01:36 PM, Surveyor observed Certified Nursing Assistant (CNA)-D and CNA-E enter R290's room to assist R290 into bed.
On 11/26/2024, at 01:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of above concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility did not ensure staff followed infection control procedures for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the Facility did not ensure staff followed infection control procedures for 3 (R13, R22 and R290) of 12 residents sampled.
* Wound care preformed for R13- staff did not follow standard of practice for hand hygiene in between glove changes and did not sanitize scissors for wound treatment.
*R290 noted to be on Enhanced Barrier Precautions (EBP), staff member observed not following standards of practice while providing high contact, incontinence care.
*Incontinence cares observed for R22, staff member observed not changing soiled gloves and did not perform hand hygiene prior to applying lotion to R22.
Findings include:
The Facility's policy, titled Handwashing/Hand Hygiene, with a last revision date of October 2023, documents in part, Administrative Practices to Promote Hand Hygiene . 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene 1. Hand Hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.
The Facility's policy, titled Enhanced Barrier Precautions, with a last revision date of October 2023, documents in part, Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) h. chronic wound care .
1.) R22 was admitted to the facility on [DATE]. R22's admission Minimum Data Set (MDS), dated [DATE], documents R22's Brief Interview for Mental Status (BIMS) score is 06, indicating R22 has severely impaired cognition. R22's admission MDS documents R22 has frequent urinary incontinence, always incontinent of bowel and dependent when performing toileting hygiene. R22's primary medical condition category is documented as medically complex conditions.
On 11/26/2024, at 10:34 AM, Surveyor observed incontinence cares for R22. Surveyor observed Certified Nursing Assistant (CNA) CNA-F perform incontinence care for R22, with CNA-G and CNA-H assisting; all CNAs were wearing gloves to provide cares. Surveyor observed the CNA's assist R22 rolling onto R22's left side. CNA-F removed R22's brief, Surveyor observed a small bowel movement. Surveyor observed CNA-F wash the fecal matter off of R22's buttocks, CNA-F then grabbed a clean towel, dried R22's buttocks. CNA-F then grabbed a small bottle of lotion, squeezed lotion into CNA-F's hand and rubbed the lotion onto R22's buttock with unchanged gloves. CNA-F did not perform hand hygiene or change gloves after performing incontinence cares for R22.
2.) R290 was admitted to the facility on [DATE]. R290's BIMS score is 13 as documented in a progress note, on 11/13/2024 at 01:55 PM. R290 has a relevant medical diagnosis of urinary retention. Surveyor noted R290 has an indwelling catheter per R290's medical record.
On 11/25/2024, at 12:33 PM, Surveyor observed R290 to have an enhanced barrier precautions (EBP) sign on door and a 3 drawer cart outside the room with personal protective equipment (PPE).
On 11/25/2024 at 01:36 PM, Surveyor observed CNA-E and CNA-D assisting R290 into bed using a Hoyer lift. Surveyor noted CNA-E and CNA-D did not don gowns, but donned gloves. Once R290 was in bed, CNA-D removed R290's pants and brief to begin performing incontinence cares. CNA-D completed cares with R290 without concerns, Surveyor asked CNA-D if R290 was on any precautions, CNA-D informed Surveyor that R290 was not on any precautions.
On 11/26/2024, at 01:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Infection Preventionist (IP)-C of above concerns.
3.) On 11/26/24, at 9:55 AM, Surveyor observed wound care for R13 completed by Infection Preventionist (IP)-C. IP-C began by utilizing hand hygiene and donning gloves and a gown.
IP-C dated two border foam dressings on the over bed table. IP-C removed the dressing on R13's mid back. IP-C removed their gloves with the used dressing and donned new gloves. IP-C did not utilize hand hygiene with the glove change. IP-C cleansed the wound and then removed their glove on their right-hand after washing the wound. IP-C then donned a new glove on their right hand. IP-C did not utilize hand hygiene with the glove change. IP-C then took scissors and cut through a package of Xeroform. IP-C cut out a section through the package. IP-C did not sanitize their scissors, nor open the package to access the dressing directly. IP-C applied the Xeroform to the wound bed via a Q-tip swab. IP-C then applied the border foam dressing.
IP-C removed their gloves and utilized hand hygiene. IP-C then donned new gloves. IP-C removed the used dressing from the sacrum area. IP-C removed their gloves and donned new gloves. IP-C did not utilize hand hygiene after the glove change. IP-C cleansed the wound then removed their right hand glove. IP-C then donned a new right glove. IP-C did not utilize hand hygiene with the glove change. IP-C used their scissors to cut a section of Xeroform through the package. IP-C did not sanitize their scissors, nor open the package to access the dressing directly. IP-C applied the Xeroform to the wound bed via a Q-tip swab. IP-C then applied the border foam dressing.
IP-C removed their gloves and donned new gloves. IP-C did not utilize hand hygiene with the glove changes. IP-C removed all the used dressing supplies and equipment IP-C then removed their gloves, and gown, in R13's bathroom. IP-C then washed their hands. Surveyor queried IP-C on hand hygiene and scissor use. IP-C stated they do not have anything to sterilize their scissors, so they cut through the packaging and they view each wound as its own contamination. They also did not think to utilize hand hygiene with glove removals.
On 11/26/24 at 3:00 PM, at the facility exit meeting, Surveyor shared the infection control concerns with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and IP-C. No further information was provided.
May 2022
14 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not provide necessary treatment and services to prevent deve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not provide necessary treatment and services to prevent development of a pressure injury and promote healing for 1 (R4) of 3 Residents with pressure injuries.
On 2/8/22 R4's significant change minimum data set indicated R4 was at risk for the development of pressure injuries. R4's plan of care for pressure injuries was not revised to include individualized interventions to prevent developing pressure injuries based upon assessment. On 3/6/22 nursing noted R4 developed a pea sized area on the sacrum and was called a stage 2. The area was not comprehensively assessed on this date. On 3/8/22 the Facility assessed the area and staged it as a stage 2 pressure injury despite the area being assessed to have 60% slough present. A Stage 2 pressure injury does not have slough in the wound bed. The Facility has continued to incorrectly stage R4's pressure injury. On 3/29/22 the wound assessment revealed the wound bed has epithelial & granulation tissue. The Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue and continued to incorrectly stage R4's pressure injury. During weekly assessments, it is indicated the pressure injury was increasing in size and there were no revision of the care plan with the last revision dated 4/17/22. On 5/17/22 R4 was observed to not be checked and/or changed for approximately 6 hours despite the facility indicating they believe the area originated as being from moisture related to incontinence.
Findings include:
The Pressure Injuries Overview, 2001 Med-Pass, Inc. (Revised March 2020) under Staging (National Pressure Injury Advisory Panel Classification System) for Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis includes Granulation tissue, slough and eschar are not present.
R4 was admitted [DATE]. R4's diagnoses includes Parkinson's Disease, hypertension, and dementia. R4 is receiving hospice services. Minimum Data Set (MDS) assessment on 6/8/21 indicated R4 was at risk for developing pressure injuries.
The potential for pressure ulcer development initiated 6/14/21 had the following interventions:
*Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 6/14/21.
* Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 6/14/21.
* No brief at night in bed, resident choice. Initiated 8/25/21.
* Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Initiated 6/14/21.
* The resident needs assistance to turn/reposition with RDS, more often as needed or requested. Initiated 6/14/21.
* Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Initiated 6/14/21.
This potential for pressure ulcer development was resolved on 4/6/22.
The significant change MDS (minimum data set) with an assessment reference date of 2/8/22 documents a BIMS (brief interview mental status) score of 4 which indicates severe impairment. R4 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use and does not ambulate. R4 is always incontinent of bowel and bladder. R4 is at risk for developing pressure injuries and is coded as not having any pressure injuries. On 2/8/22 R4's significant change minimum data set indicated R4 was at risk for the development of pressure injuries. Despite this risk, there were no individualized approaches in the care plan to prevent the development of a pressure injury.
The nurses note dated 3/6/22 documents Patient has a small pea sized stage 2 pressure injury on sacrum. Skin prep applied around injury and mepilex dressing applied and dated.
The nurses note dated 3/7/22 documents Resident alert/responsive, NAD (no apparent distress). Mepilex dressing covers sacrum area. Resident repositioned side-to-side as tolerated. No expressions of pain. Will continue to monitor. Afebrile.
The nurses note dated 3/7/22 documents New partial thickness lesion noted last night per NOC (night) shift-upon assessment wound is in intergluteal fold about 2 cm (centimeters) distal from bony prominence, wound edges diffuse and macerated, wound bed is moist with small amount serous drainage-reviewed w MD (with medical doctor) who states he will be present tomorrow morning for further evaluation to determine dx (diagnoses) pressure vs moisture-frosted w (with) zinc barrier cream in the interim. Spoke with POA (power of attorney) who verbalizes understanding and agrees with plan of care.
The nurses note dated 3/8/22 documents Resident discussed by IDT this date r/t (related to) risk management. Resident is alert not oriented, not always able to make basic needs known. Remains on hospice services and is a DNR (no not resuscitate). Residents activated POA is her niece who is involved in her POC (plan of care). Resident has new stage 2 to coccyx. Area has been assessed by wound nurse. Treatment is in place and family aware. Appetite remains fair to good depending on residents mood. No other concerns noted at this time. Resident continues to get up daily in Broda and be in common areas and participate daily in activities.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.2, Width 0.6, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Granulation tissue present (beefy red) and Slough tissue present (yellow, tan, white stringy). For Describe the extent (%) of necrosis and/or slough in the wound bed documents 60.
Surveyor noted Facility staff incorrectly Staged R4's pressure injury as a Stage 2 pressure injury does not have slough in the wound bed. Subsequent assessments, noted below, also incorrectly staged the pressure injury
The resident has stage 2 pressure ulcer to medial intergluteal cleft initiated & revised on 3/8/22 has the following interventions:
* The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 1 person assist and pillows. Initiated & revised 3/8/22 Surveyor noted R4 is assessed as requiring extensive assist of 2 staff for bed mobility.
* Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 3/8/22.
* Avoid positioning the resident on back as she allows. Initiated 3/8/22 & revised 4/8/22.
* Check air mattress QS (every shift). Initiated 4/17/22.
* If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Initiated 3/8/22.
* Orange top barrier cream q shift (every shift) and PRN (as needed) with cares, remove top soiled layer and replace as needed. Initiated 3/8/22.
* Weekly treatment documentation to include measurement of each area of skin breakdown's width,
length, depth, type of tissue and exudate. Initiated 3/8/22.
Surveyor noted the interventions were not developed until after R4 developed a pressure injury with slough.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.2, Width 0.6, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Granulation tissue present (beefy red) and Slough tissue present (yellow, tan, white stringy). For Describe the extent (%) of necrosis and/or slough in the wound bed documents 60.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Granulation tissue present (beefy red) and Slough tissue present (yellow, tan, white stringy). For Describe the extent (%) of necrosis and/or slough in the wound bed documents 60.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 0.8, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 0.8, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 0.8, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue.
The nurses note dated 4/16/22 documents Writer was called to room by care staff to assess wound on coccyx area. Wound is 1 cm in length x 1.4 cm in width and .5 cm depth. Area washed and cleansed thoroughly and barrier cream applied to area.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue. The Facility continues to incorrectly stage R4's pressure injury.
Surveyor noted there was no revision in R4's plan of care after the pressure injury increased in size.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue.
The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue and continues to incorrectly stage R4's pressure injury.
The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk.
The quarterly MDS (minimum data set) with an assessment reference date of 5/11/22 documents a BIMS (brief interview mental status) score of 3which indicates severe impairment. R4 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfers, and does not ambulate. R4 is always incontinent of bowel and bladder, is at risk for pressure injury development and is coded as having one Stage 2 pressure injury.
On 5/17/22 at 7:26 a.m. Surveyor observed R4 sleeping in a Broda chair in the dining room. R4 is wearing gripper socks on her feet with a pillow under her feet. There is a Hoyer sling under R4 and the back of the chair is reclined slightly. Surveyor noted there is no care planned intervention regarding leaving the Hoyer sling under R4 when seated in the Broda chair.
On 5/17/22 at 10:29 a.m. Surveyor noted R4 is not on the unit and is on another floor for an activity.
On 5/17/22 at 12:09 p.m. Surveyor observed R4 sitting in a Broda chair at a table in the dining room with a red beverage in front of her.
On 5/17/22 at 12:41 p.m. Surveyor observed R4 continues to be sitting at a table in the dining room.
On 5/17/22 at 12:52 p.m. Surveyor observed RN (Registered Nurse) Manager-M wheeling R4 down the hallway stating to Surveyor she is going to let R4 sit up for a little as she had a magic cup. RN Manager-M wheeled R4 into her room informing Surveyor they are going to let her sit up then do her dressing and bed bath.
On 5/17/22 at 1:10 p.m. Surveyor observed CNA-Q & CNA-P in R4's room with a Hoyer lift. Surveyor observed CNA-Q & CNA-P attached the Hoyer sling which was under R4 to the Hoyer lift, raise R4 off her chair, wheel R4 over to the bed and lower R4 onto the bed.
At 1:14 p.m. RN (Register Nurse) Manager-M and RN-E entered R4's room.
At 1:15 p.m. R4 was positioned side to side to remove the sling, lower the pants and R4's incontinence product was unfastened. CNA-Q washed R4's frontal perineal area and removed the wet incontinence product. After CNA-Q completed incontinence cares, RN Manager-M removed the dressing, measured the pressure injury indicating measurements of 1.0 cm (centimeter) length, 0.6 cm width and 0.2 depth stating there is a line of tissue growing in the wound bed. RN Manager-M completed R4's treatment according to physician orders.
On 5/17/22 at 1:38 p.m. Surveyor asked CNA-P what she does for R4. CNA-P informed Surveyor the night shift gets R4 up, she helps her with breakfast & lunch and R4 goes to activities. R4 will lay down after lunch and rotate R4 every two hours. Surveyor inquired when incontinence cares are provided to R4. CNA-P informed Surveyor depends when night shift gets her up. Surveyor asked CNA-P if this was the first time incontinence cares were provided today to R4. CNA-P replied yes. Surveyor noted R4 who has a coccyx pressure injury has not been checked &/or changed for approximately six hours.
On 5/17/22 at 1:46 p.m. Surveyor met with RN Manager-M to discuss R4. Surveyor asked RN Manager-M, who is the wound nurse for the Facility, how R4 developed the pressure injury. RN Manager-M informed Surveyor she thinks it started as moisture. RN Manager-M explained hospice was using a different brand of incontinence briefs and then they switched back to a high absorbency brief. RN Manager-M informed Surveyor once the skin was compromised the area opened up. RN Manager-M informed Surveyor they have since gotten a roho cushion for R4's Broda chair. Surveyor asked if R4 received the roho cushion after development of the pressure injury. RN Manager-M replied yes. Surveyor asked RN Manager-M why she staged the pressure injury as a Stage 2. RN Manager-M informed Surveyor the doctor said it was partial thickness loss. Surveyor informed RN Manager-M a Stage 2 pressure injury does not have slough in the wound bed and explained it would be a Stage 3 or unstageable depending on the percentage of slough. RN Manager-M informed Surveyor she would go in and fix it. Surveyor informed RN Manager-M of today's observation of R4 not being checked &/or changed for approximately 6 hours.
On 5/18/22 at 3:18 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.
On 5/19/22 at 8:30 a.m. Surveyor asked RN Manager-M why her assessments don't include the percentage of granulation and epithelial tissue. RN Manager-M informed Surveyor she was informed she needs to do percentage of the wound bed when there is slough.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure 1 (R2) of 12 Residents reviewed for code status had their code ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure 1 (R2) of 12 Residents reviewed for code status had their code status accurately documented in their medical record.
R2's electronic medical record documented R2 is a full code [should receive CPR (cardiopulmonary resuscitation)] while the paper record documented R2 is a DNR (do not resuscitate).
Findings include:
The Advanced Directives policy 2001 Med-Pass, Inc (Revised [DATE]) under Policy Interpretation and Implementation documents 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. and 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive.
R2 was admitted to the facility on [DATE].
The top portion of R2's electronic record documents CPR.
The order summary report with active orders as of [DATE] includes a physician order with an order date of [DATE] which documents Advanced Directive: CPR - Full Code (Cardiopulmonary Resuscitation). The physician signed the order summary on [DATE] which includes a statement I have approved these orders for [R2's name]. Total pages 3.
Surveyor noted this physician order in both the electronic and paper record.
The care plan initiated & revised on [DATE] documents [R2] desires to be a Full Code. CPR.
On [DATE] Surveyor reviewed R2's paper medical record and noted a pink (red) sheet of paper with large black letters DNR.
The paper medical record also includes a Preference for Resuscitation form. NO Cardiopulmonary Resuscitation is checked. This form dated [DATE] is signed by R2's power of attorney for health care and witnessed by R2's daughter.
The State of Wisconsin Emergency Care Do Not Resuscitate Order (DNR) is signed by R2's power of attorney on [DATE] and R2's physician on [DATE].
On [DATE] at 10:51 a.m. Surveyor asked RN (Registered Nurse)-E if she needed to find out a Resident's code status where would she find this information. RN-E informed Surveyor she would go to the hard (paper) chart and look at the paper which is either green for CPR or red for DNR. RN-E informed Surveyor she could also look under the advanced directive section and as the last report look in the computer. Surveyor asked RN-E if a Resident or their representative change the code status who is responsible for updating the Resident's medical record. RN-E informed Surveyor it is her understanding social service would update this. Surveyor inquired who would obtain the physician's order for the code status change. RN-E informed Surveyor she has always gone to social service any time a POA (power of attorney) changes the code status. RN-E indicated advanced directives is through social service.
On [DATE] at 11:06 a.m. Surveyor asked SW (Social Worker)-C what is the process for Resident's code status. SW-C informed Surveyor the code status paper work is filled out by nursing upon admission and then if there are any changes. SW-C informed Surveyor they verify code status quarterly, annually, as well as during care conferences. Surveyor asked SW-C who would contact the physician for new orders if there is a change in code status. SW-C informed Surveyor the floor nurses or HSM (Health Services Manager)-D. Surveyor asked how HSM-D would become aware of a Resident's code status change. SW-C informed Surveyor HSM-D has the State DNR form and she has face to face interaction with the nurses.
On [DATE] at 11:10 a.m. Surveyor asked HSM-D if she is involved in changes for Resident's code status. HSM-D informed Surveyor she is not directly involved with Resident's code status but will help out if the power of attorney lives out of state. HSM-D informed Surveyor on admission the nurse will ask about the code status and put the paper, either green or red, in the medical record. Surveyor asked what happens when there is a change in code status. HSM-D informed Surveyor the nurses have access to paper in the cabinet or can ask us. Surveyor asked HSM-D if she was involved with R2's change of code status. HSM-D replied not directly that I remember. Surveyor asked who is responsible for updating the care plan. HSM-D informed Surveyor she wasn't sure if it was SW-C, MDS (minimum data set) or the DON (Director of Nursing).
On [DATE] at 11:14 a.m. Surveyor asked SW-C who would updates a Resident's care plan when there is a change in code status. SW-C informed Surveyor either nursing or social services and stated obviously that can change 24 hours a day and I'm not here.
On [DATE] at 11:17 a.m. Surveyor asked RN (Registered Nurse) Manager-M to explain the process when a Resident's code status is changed. RN Manager-M explained a CPR or no CPR is signed by the responsible party and if the code status is changed to DNR there is a state form that has to be signed by the responsible party and the physician. Once the physician signs that form they can active the code status. RN Manger-M explained the physician order and signage in the chart is changed. RN Manager-M explained this is audited by the social service team. Surveyor asked RN Manager-M to open R2's medical record in the computer. Surveyor showed RN Manager-M R2's code status is CPR in the electronic record while the hard (paper) record is DNR. RN Manager-M stated it should not be different and informed Surveyor she is going to change R2's code status in the computer.
On [DATE] at 3:03 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview & record review, the Facility did not ensure 1 (R9) 1 allegation of neglect was reported to the State Survey Agency.
Findings include:
The Abuse Prevention Program reviewed/updated ...
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Based on interview & record review, the Facility did not ensure 1 (R9) 1 allegation of neglect was reported to the State Survey Agency.
Findings include:
The Abuse Prevention Program reviewed/updated 11-2018 under section VII Reporting of Potential Abuse documents 1. Initial Reporting of Allegations Any allegations of abuse will be reported to the Administrator immediately and to the State Department of Health and the resident's representative as soon as possible within 24 hours. 2. Five-day Final Abuse Investigation Report. Within five working
days after the report of the occurrence a complete written report of the conclusion of the investigation, including steps the community has taken in response to the allegation, will be sent to the Department of Health.
R9's annual MDS (minimum data set) with an assessment reference date of 2/10/22 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R9 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, and is always incontinent of bowel and urine.
The nurses note dated 3/27/22 documents At 0800 (8:00 a.m.) this shift, res (resident) was on call light , cna (Certified Nursing Assistant) reported res complaining of not being changed all night stated I have been sitting in urine all night, no one came in to change me. AM (morning) CND (sic) this shift checked res and noted that brief is dry and chuck pad has a small wet area noted. Res then was changed right away by AM shift and redirected res that her brief is dry but res still insisted that she was not changed all night.
On 5/18/22 at 3:11 p.m. Surveyor asked Administrator-A if R9's allegation of neglect which was reported on 3/27/22 was report to the State agency. Administrator-A informed Surveyor the allegation was not reported.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the Facility did not ensure that an allegation of possible neglect was investigated...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the Facility did not ensure that an allegation of possible neglect was investigated for 1 (R9) of 1 Residents.
On 3/27/22 R9 reported she had not been changed all night which is an allegation of neglect. The Facility did not investigate this allegation.
Findings include:
The Abuse Prevention Program reviewed/updated 11-2018 under section VI. Investigation of Abuse, Neglect, or Misappropriation Allegations and Response documents 1. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation.
R9's annual MDS (minimum data set) with an assessment reference date of 2/10/22 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R9 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, and is always incontinent of bowel and urine.
The nurses note dated 3/27/22 documents At 0800 (8:00 a.m.) this shift, res (resident) was on call light, cna (Certified Nursing Assistant) reported res complaining of not being changed all night stated I have been sitting in urine all night, no one came in to change me. AM (morning) CND (sic) this shift checked res and noted that brief is dry and chuck pad has a small wet area noted. Res then was changed right away by AM shift and redirected res that her brief is dry but res still insisted that she was not changed all night.
On 5/17/22 at 3:03 p.m. during the end of the day meeting with Administrator-A and DON (Director of Nursing)-B Surveyor asked for an investigation regarding R9's allegation of neglect which she reported on 3/27/22.
On 5/18/22 Surveyor reviewed the Facility's investigation which consisted of LPN (Licensed Practical Nurse)-J's handwritten statement and a two page skin observation tool. Surveyor did not note any other staff statements.
LPN-J's statement dated 3/27/22 documents To Whom it may Concern: Rm (room): [room number] On 3/27/22 res (resident) slightly confused and complained about she was not being changed all night. AM (morning) CNA & writer noted and assessed res after the complained. Observed small amount of urine noted in chuck, brief is dry. Res. redirected but went ahead and did ADL's (activities daily living) to at peace resident. Resident not in distress, baseline pleasant.
On 5/18/22 at 12:10 p.m. Surveyor asked DON-B if information provided was the complete investigation. DON-B indicated it was and informed Surveyor this happened over the weekend, when she followed up with LPN-J R9 was not saturated with urine didn't feel like it was a concern based off CNA-J's statement and assessment. DON-B informed Surveyor R9 is a heavy wetter so having very little wetness she didn't feel it was truthful. Surveyor asked DON-B if she spoke to any of the night staff on duty or get any statements. DON-B informed Surveyors she took what LPN-J wrote and stated didn't think it was necessary. Surveyor informed DON-B R9 made an allegation of possible neglect and an investigation including speaking to the night shift staff should have been conducted to rule out possible neglect.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R233 was admitted to the facility with diagnoses of Unspecified Osteoarthritis, Hyperlipidemia, and Major Depressive Disorder...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R233 was admitted to the facility with diagnoses of Unspecified Osteoarthritis, Hyperlipidemia, and Major Depressive Disorder on 10/8/21. R233 discharged to the hospital on [DATE]. R233 was her own person.
On 5/16/22 at 1:51 PM, Surveyor reviewed R233's electronic medical record (EMR) and noted the following documentation:
10/18/2021 11:59 Discharge Summary Note Text: R233 discharged at 1140 10/18/21 via ambulance. R233 will be going to hospital to seek psychiatric help due to suicidal ideations. R233 received morning meds.
R233's EMR did not include documentation that a transfer notice had been given to R233 and/or representative for the hospitalization.
On 5/18/22 at 3:07 PM, Surveyor shared the concern with Director of Nursing (DON-B) and Administrator (NHA-A) of R233's EMR containing no transfer form to the hospital being completed and sent with R233. No further information was provided at this time by the facility.
Based on interview and record review, the facility did not ensure 2 (R33, R233) of 3 sampled residents reviewed for discharged received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman.
R33 was transferred to the hospital on [DATE]. R33 and/or the resident representative was not given a transfer notice.
R233 was transferred to the hospital on [DATE]. R233 and/or the resident representative was not given a transfer notice.
Findings include:
On 5/19/22 the facility's policy titled Transfer or Discharge Documentation dated 12/16 was reviewed and read: 4b. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record. That an appropriate notice was provided to the resident and/or legal guardian,
1. On 05/17/22 The Surveyor reviewed R33's medical record and it indicated R33 was transferred to the hospital on [DATE]. The resident's medical record did not include documentation that a transfer notice had been given to the resident and/or representative for the hospitalization.
On 05/19/22 at 9:45 AM, the Surveyor interviewed Director of Nurses (DON)-B regarding resident transfer notices. DON-B indicated the facility could not find any documentation that R33 or her legal representative was given a transfer notice when she was discharged to the hospital on 2/23/22 and should have been,
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R233 was admitted to the facility with diagnoses of Unspecified Osteoarthritis, Hyperlipidemia, and Major Depressive Disorder...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R233 was admitted to the facility with diagnoses of Unspecified Osteoarthritis, Hyperlipidemia, and Major Depressive Disorder on 10/8/21. R233 discharged to the hospital on [DATE]. R233 was her own person.
On 5/16/22 at 1:51 PM, Surveyor reviewed R233's electronic medical record (EMR) and noted the following documentation:
10/18/2021 11:59 Discharge Summary Note Text: R233 discharged at 1140 (11:40 a.m.)10/18/21 via ambulance. R233 will be going to hospital to seek psychiatric help due to suicidal ideation's. R233 received morning meds.
R233's EMR did not include documentation that a bed hold notice had been given to R233 and/or representative for the hospitalization.
On 5/18/22 at 8:04 AM, Director of Nursing (DON)- B stated the expectation is that the bedhold notice is done upon transfer to the hospital. Admissions will get it after the admission to the hospital if not done at time of transfer.
On 5/18/22 at 3:07 PM, Surveyor shared the concern with Director of Nursing (DON-B) and Administrator (NHA-A) of R233's EMR containing no documentation that a bedhold notice had been given to R233 and/or representative. No further information was provided at this time by the facility.
Based on interview and record review, the facility did not ensure that 2 of 3 Residents (R33 and R233) reviewed for hospitalizations received written information of the duration of the bed hold policy, the reserve bed payment payment policy and the right to return to the facility.
R33 was transferred to the hospital on [DATE]. R33 and/or the resident representative was not given a bed hold policy notice.
R233 was transferred to the hospital on [DATE]. R233 and/or the resident representative was not given a bed hold policy notice.
Findings include:
On 5/19/22 the facilities policy titled, Bed-holds and Returns dated 03/17 was reviewed and read: 3. Prior to a transfer, written information will be given to the residents and the resident representatives that explain in detail -
a. The rights and limitations of the resident regarding bed-holds.
b. The reserve bed payment policy as indicated by the state plan.
c. The facility per diem rate required to hold a bed and
d. The details of the transfer.
1. On 5/17/22 The Surveyor reviewed R33's medical record and it indicated R33 was transferred to the hospital on [DATE]. The resident's medical record did not include documentation that a written notice of the bed hold policy had been given to the resident and/or representative for the hospitalization at the time of transfer.
On 05/19/22 at 9:45 AM, the Surveyor interviewed Director of Nurses (DON)-B regarding resident bed hold notices. DON-B indicated the facility could not find any documentation that R33 or her legal representative was given a bed hold notice when she was discharged from the hospital on 2/23/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not develop and implement an effective discharge planning process for 2 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not develop and implement an effective discharge planning process for 2 (R233 and R235) of 3 Residents reviewed.
*R233's baseline care plan dated 10/8/21 documents R233 was to discharge home, however, discharge planning was not completed and R233 was transferred to the hospital on [DATE].
*R235's care plan documents R235 was to be discharged back to R235's assisted living. R235's electronic medical record (EMR) contains no documentation a discharge planning meeting was held and R235 discharged to another skilled nursing facility.
Findings Include:
Surveyor reviewed the facility's policy and procedure 'Discharging the Resident' revised 12/16 and notes the following:
Preparation
1. The Resident should be consulted about the discharge.
2. Discharges can be frightening to the Resident. Approach the discharge in a positive manner.
5. If the Resident is being discharged home, ensure that Resident and/or responsible party receive teaching and discharge instructions.
6. If the Resident is being discharged to a hospital or another facility, ensure that transfer discharge summary is completed and telephone report is called to the receiving facility.
1. R233 was admitted to the facility with diagnoses of Unspecified Osteoarthritis, Hyperlipidemia, and Major Depressive Disorder on 10/8/21. R233 discharged to the hospital on [DATE]. R233 was her own person.
Surveyor reviewed R233's admission Minimum Data Set (MDS) dated [DATE] and notes that R233's Brief Interview for Mental Status (BIMS) score is 14, indicating R233 was cognitively intact for daily decision making. R233's Patient Health Questionnaire (PHQ-9) score is 7 indicating mild depression. R233's MDS also documents that R233 required limited assist for bed mobility, transfers, and dressing.
Surveyor reviewed R233's EMR and notes the following entries pertinent to R233's discharge:
10/11/2021 15:45 admission Summary Note Text: 10-11-2021. Care conference held on this date. R233 will receive Physical (PT) and Occupation therapy (OT) with the goal of discharging home. R233 is alert and understands others and is adjusting well to placement.
R233's social service assessment dated [DATE] documents R233's discharge goal was to return home and had no previous psychological interventions
10/12/2021 15:07 Plan of Care Note Text: IDT (Interdisciplinary Team) met on today's date for risk meeting. R233 is receiving PT/OT services with the goal of returning home with R233's partner. Standard hip precautions in place. Encouragement to remain in facility provided frequently due to concern about home being cleaned by family members. Resident is alert and oriented and able to make needs known x's 4. Placement remains appropriate at this time.
10/14/2021 16:24 Plan of Care Note Text: Social Worker (SW-C) spoke with R233's son on today's date. R233's son concerned with discharge as R233 is unable to return to R233's previous living arrangements with partner. Home with no running water and full of items related to hoarding. Son will come to Wisconsin within 2 weeks to assist in next steps. Referral made to Care Patrol on today's date. R233 also provided list of long-stay hotel options in the Milwaukee Area.
R233's baseline care plan dated 10/14/21 documents R233's goal was to return home and was at risk for mood disturbance.
Surveyor notes that a 'post-discharge plan of care' was completed for R233, however, the discharge location is blank.
On 10/15/21, a physician's order was received that R233 may discharge with PT/OT to eval and treat.
A Physical Therapy Discharge summary dated [DATE] indicates -[R233] is contact guard with 2 wheeled walker for all transfers and gait distances and at least 1 rail for stair negotiation. R233 unfortunately received an insurance denial and lost appeal so R233 is discharged from therapy. R233's home is not safe to return due to hoarding so [SW-C] is working on alternative placement.
A Occupation Therapy Discharge summary dated [DATE] documents-[R233] has issues become apparent of psych with R233 not able to return to live with significant other with inadequate ability to care for self and has some hoarding and sanitary issues with no functioning place to discharge. R233 had made progress with limitation of distractibility for safe follow through.
A 10/18/2021 11:59 Discharge Summary Note Text indicates: R233 discharged at 11:40 AM, 10/18/21 via ambulance. R233 will be going to hospital to seek psychiatric help due to suicidal ideation's. R233 received morning meds.
On 5/18/22 at 10:53 AM, Surveyor interviewed SW-C in regards to R233's discharge. SW-C stated that R233 had been staying with a boyfriend. SW-C stated the boyfriend's daughter wanted to break up the relationship and did not want R233 to be discharged back to live with R233's boyfriend. SW-C stated that R233 was focused on being discharged during the stay at the facility. SW-C spoke with R233 about options of discharge since R233 could not go home. SW-C spoke to R233 about a hotel. SW-C stated that R233 became anxious with the whole situation. SW-C obtained information on hotels and provided R233 the information. SW-C stated that R233 did not follow-up on the hotels. SW-C confirmed that SW-C did not speak to R233 about the process of applying for Medicaid. SW-C received notification from Health Services Manager (HSM-D) that R233 wanted to sign herself into psychiatric services for treatment of hoarding. Surveyor shared the concerns with SW-C that R233's EMR does not contain documentation that discharge planning was being completed for R233. Surveyor also expressed that R233's EMR contained no documentation of any anxiety issues until the last day. SW-C had no further information.
On 5/18/22 at 11:38 AM, Surveyor spoke to HSM-D in regards to R233. HSM-D stated that R233 spoke to HSM-D about the anxiety of hoarding, and wanting to go home, and wanted help at the hospital. HSM-D stated R233 was not anxious in the beginning of R233's stay but when discharge planning started, is when R233 started having the anxiety. (R233) was upset a couple of days before going to the hospital. HSM-D confirmed R233 did not express any actual thoughts of harming self.
On 5/18/22 at 3:07 PM, Surveyor shared the concern with Director of Nursing (DON-B) and Administrator (NHA-A) of R233's discharge planning not being completed with lack of documentation in R233's EMR. No further information was provided at this time. Surveyor shared that a regular re-evaluation to identify changes in R233's discharge plan did not occur. Surveyor shared that R233's care plan had not been updated with R233's discharge plans as they changed.
On 5/19/22 at 10:40 AM, Occupational Therapist (OTR-H) stated R233 was highly distractible in therapy but cooperative, and was preoccupied. OTR-H stated this did hamper R233's progress in therapy for safety issues.
On 5/19/22 at 11:11 AM DON-B confirmed the expectation is that staff should be charting in the Resident's EMR when a Resident expires, discharges to community, goes to a skilled nursing facility(SNF), or hospital.
2. R235 was admitted to the facility with diagnoses of Type 1 Diabetes Mellitus, Ataxia, and Cerebellar Stroke Syndrome on 1/11/22. R235 discharged to another skilled nursing facility on 2/2/22. R235 was her own person.
R235's admission MDS (Minimum Data Set) dated 1/17/22 documents R235's BIMS (Brief Interview for Mental Status) to be a 15, indicating R235 was cognitively intact for daily decision making. R235 required extensive assistance for bed mobility, transfers, dressing, toileting, and hygiene.
Surveyor notes that R235's discharge MDS dated [DATE] documents R235 required extensive assistance with bed mobility and toileting, but improved with needing only limited assistance for transfers, dressing, and hygiene.
Surveyor notes that R235's care plan has a discharge goal of R235 returning to R235's assisted living.
Surveyor reviewed R235's EMR and notes the following documentation:
On 1/13/2022 14:45 a Plan of Care Note Text indicates: Interdisciplinary Team (IDT) met with R235 and daughter on today's date for a care plan meeting. R235 will receive PT/OT services. R235 is alert and oriented x's 4. Previously living at assisted living and independent with self-cares.
On 1/17/2022 11:43 a Plan of Care Note Text indicates: A care conference was held on 1-13-22. R235 plans on discharging to assisted living and has strong family support.
Surveyor notes there is a physician order dated 1/27/22 for R235 to discharge with outpatient PT,OT, and ST.
On 1/31/2022 09:29 No Type Specified Note Text: IDT met on today's date for risk management meeting. R235 was previously living at assisted living with goal to discharge on [DATE]. R235 will continue to receive PT/OT services upon discharge. R235 is alert to person, place, time and generally situation [sic].
Surveyor notes there is no other documentation of discharge planning for R235.
R235 received Notice of Medicare Non-Coverage (NOMNC) on 1/31/22 that services would be ending on 2/3/22.
On 5/17/22 at 11:19 AM, Surveyor spoke to R235's family member who stated they were concerned that R235 was not improved with transfer status per assisted living requirements and was not ready to be discharged back to the assisted living. They requested a discharge planning meeting but was informed that R235 was scheduled to leave the facility. Family member appealed the NOMNC and was waiting for the decision. In the meantime, family arranged for R235 to be admitted to another SNF for rehabilitation. (R235) was definitely not safe in returning to the assisted living. She had to be completely independent. (R235) even said (R235) wasn't ready to return home.
On 5/18/22 at 10:43 AM, Surveyor spoke to SW-C in regards to R235. SW-C stated that family felt R235 needed more rehabilitation. SW-C indicated the assisted living could meet R235's needs. Surveyor shared the concern there was no physician's order for R235 to go to another SNF and there was no documentation in R235's EMR of discharge planning or where, when, and condition of R235 being discharged .
SW-C provided documentation of an email dated 2/1/22 which was sent to the assisted living and documented the following:
I've attached signed orders for R235 who is planned to return on Friday. I sent clinical over last week and haven't heard anything. Could you please check with your director of nursing to determine if R235 is safe to return. We are open for onsite visits as well.
Surveyor noted there was no documentation of a response from the assisted living.
On 5/18/22 at at 3:07 PM, Surveyor shared the concern with DON-B and NHA-A of R235's discharge planning not being completed, no documentation of a discharge planning meeting and no documentation of R235's discharge from the facility. Surveyor shared that a regular re-evaluation to identify changes in R235's discharge plan did not occur. Surveyor shared that R235's care plan had not been updated with R235's discharge plans as they changed
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility did not ensure that 1 (R132) of 1 Residents reviewed for showers and who wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility did not ensure that 1 (R132) of 1 Residents reviewed for showers and who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good hygiene.
R132 did not receive showers according to her shower schedule.
Findings include:
R132 was admitted to the facility on [DATE] with diagnoses that included Compression fracture of the vertebra. R132 was discharged on 10/29/21.
On 5/18/21, R132's personal care documentation was reviewed and read: Showers Wednesday and Saturday AM (day) shift. 10/20/21, 10/23/22, and 10/27/22 under bathing for R132 a number 8 is charted. 8 means did not occur according to the documentation key.
On 5/18/22 R132's admission MDS (Minimum Data Set) assessment, with an assessment reference date of 10/23/21 was reviewed and under bathing it indicated that the activity did not occur.
On 5/18/22 R132's medical record was reviewed and there was no documentation that R132 refused any showers offered.
On 05/19/22 at 8:22 AM Director of Nurses (DON)-B indicated there was no evidence that R132 received any showers while she was at the facility or that R132 refused her showers.
On 5/19/22, the facility's procedure titled: Bath, Shower/Tub, dated 2/2018 was reviewed and read: If the resident refused the shower/ tub bath , document refusal. Notify the supervisor/nurse if the resident refuses the shower/tub bath.
The above findings were shared with the Administrator and Director of Nurses on 5/19/22 at 10:30 AM. Additional information was requested if available. None was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure that 2 (R4 & R15) of 4 Residents reviewed for acc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure that 2 (R4 & R15) of 4 Residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents.
* On 5/16/22 R4 was observed being transferred with an EZ stand lift. R4's care plan documented R4 should be transferred with a Hoyer lift.
* R15 did not have her call light within reach and left floor mat was not next to R15's bed according to the plan of care.
Findings include:
1.) R4's diagnoses includes Parkinson's Disease, hypertension, and dementia.
The ADL (activities daily living) self care performance deficit care plan initiated 6/14/21 & revised 5/16/22 includes an intervention initiated 6/14/21 & revised 4/17/22 of TRANSFER: The resident is able to: MAX (maximum) A-2 (assist two) Hoyer lift.
The quarterly MDS (minimum data set) with an assessment reference date of 5/11/22 documents a BIMS (brief interview mental status) score of 3which indicates severe impairment. R4 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfers, and does not ambulate.
The CNA (Certified Nursing Assistant) care card dated 5/14/22 under the section transfers for R4 Transfer EXT (extensive) A2 (assist two) WITH HOYER.
On 5/16/22 at 1:22 p.m. Surveyor observed CNA-N inform R4 she was going to take off her foot pedals from the broda chair.
At 1:24 p.m. CNA-O entered R4's room with an EZ stand lift and placed gloves on. The EZ stand was placed in front of R4, the sling was placed around R4 and hooked up to the EZ stand lift. CNA-N had R4 place her hands on the handle of the lift, R4 stated this is not good and CNA-O responded better safe than sorry. R4 was raised off the broda chair, wheeled over to the bed, R4's pants were lowered and R4 was lowered onto the bed. R4 was unhooked from the EZ stand lift, the sling was removed, and CNA-N informed R4 she was going to lay R4 down. CNA-N swung R4's legs so that R4 was laying on the bed.
On 5/17/22 at 1:07 p.m. Surveyor observed CNA-Q & CNA-P in R4's room with a Hoyer lift. Surveyor inquired if they always use a Hoyer lift to transfer R4. CNA-Q & CNA-P replied yes. Surveyor asked if they have ever transferred R4 with an EZ stand lift. CNA-P informed Surveyor they used to but R4 can't stand since her decline so they haven't used an EZ stand. Surveyor then observed CNA-Q & CNA-P attached the Hoyer sling which was under R4 to the Hoyer lift, raise R4 off her chair, wheel R4 over to the bed and lower R4 onto the bed.
On 5/17/22 at 1:13 p.m. Surveyor asked CNA-P about the EZ stand lift. CNA-P explained therapy assessed R4 and R4 can't really stand which puts a lot of pressure under R4's arms & shoulders. CNA-P also informed Surveyor R4 is so shaky R4 can't really hold onto the EZ stand handles.
On 5/17/22 at 3:03 p.m. Surveyor informed Administrator-A and DON (Director of Nursing)-B of the observation of R4 being transferred not according to the plan of care on 5/16/22.
2.) R15's diagnoses includes hypertension, atrial fibrillation, Parkinson's disease and dementia with behavioral disturbances.
The care plan [R15] is at high risk for falls initiated 3/31/17 & revised 3/22/21 includes an interventions of Be sure [R15's] call light is within reach and encourage the her to use it for assistance as needed. initiated 3/31/17 & revised 4//28/18 and floor mats on each side of bed initiated 5/15/20 & revised 4/9/22.
The nurses note dated 2/10/22 includes documentation of Alert and oriented to self and time at times. Makes her needs know by using the call light or calling the nurses desk with her room phone .
The annual MDS (minimum data set) with an assessment reference date of 4/8/22 documents a BIMS (brief interview mental status score) of 13 which indicates cognitively intact. R15 requires extensive assistance with two plus person physical assist and during the assessment period did not transfer or ambulate. R15 is coded as not having fallen since prior assessment period.
The Morse fall risk assessment dated [DATE] has a risk score of 75 which indicates high risk for falling.
The nurses note dated 5/1/22 documents Resident restless this shift, c/o (complaint of) pain , refused meds and the PRN (as needed) percocet offered writer provided res (resident) other choice of meds MS04 (morphine sulphate) to help with pain since res states i can't swallow the pills . Resident refused to take it. Constantly on light for c/o pain but refused to take pain meds (medication), refused to be repositioned. At 1325 (1:25 p.m.) res asked for pain med and her AM (morning) med and took the AM scheduled med and percocet. Needs met and anticipated. Call light within reach.
The CNA (Certified Nursing Assistant) care card dated 5/14/22 under the Special Equipment/Safety section includes Bed in lowest position as she allows with fall mat on both side of bed.
On 5/16/22 at 10:17 a.m. Surveyor observed R15 in bed on her back with the head of the bed elevated. Surveyor observed R15's call light is hanging down on the left side of the bed towards the floor and is not within R15's reach. Surveyor observed there is a mat on the floor along the right side of the bed. The floor along the left side of R15's bed does not have a mat.
On 5/17/22 at 7:33 a.m. Surveyor observed R15 asleep in bed on her back. Surveyor observed R15's call light is hanging down on the left side of the bed towards the floor and is not within R15's reach. Surveyor observed there is a mat on the floor along the right side of the bed. The floor along the left side of R15's bed does not have a mat.
On 5/17/22 at 10:33 a.m. Surveyor observed R15 continues to be asleep in bed on her back. Surveyor observed R15's call light is hanging down on the left side of the bed towards the floor and is not within R15's reach. Surveyor observed there is a mat on the floor along the right side of the bed. The floor along the left side of R15's bed does not have a mat.
On 5/17/22 at 12:12 p.m. Surveyor observed R15 is bed on her back with the head of the bed elevated. Surveyor observed R15's call light is hanging down on the left side of the bed towards the floor and is not within R15's reach. Surveyor observed there is a mat on the floor along the right side of the bed. The floor along the left side of R15's bed does not have a mat.
On 5/17/22 at 2:04 p.m. Surveyor observed R15 in bed on her back with her eyes closed. Surveyor observed R15's call light is hanging down on the left side of the bed towards the floor and is not within R15's reach. Surveyor observed there is a mat on the floor along the right side of the bed. The floor along the left side of R15's bed does not have a mat.
On 5/18/22 at 8:25 a.m. Surveyor observed from the hallway R15 yelling out help me. Surveyor entered R15's room and observed R15 in bed on her back. Surveyor observed the call light is hanging down on the left side of the bed and is not within R15's reach. Surveyor asked R15 what she needed. R15 informed Surveyor she wanted something to drink. Surveyor explained Surveyor doesn't work at the Facility and would go get someone for her. Surveyor also observed there is a mat on the floor along the right side of the bed. The floor along the left side of R15's bed does not have a mat.
At 8:26 a.m. Surveyor asked CNA (Certified Nursing Assistant)-N if R15 can use her call light. CNA-N replied yes. Surveyor informed CNA-N R15 would like something to drink.
At 8:30 a.m. Surveyor asked CNA-N if R15 gets out of bed. CNA-N informed Surveyor R15 prefers to stay in bed. Surveyor asked if there are suppose to be two mats next to R15's bed. CNA-N informed Surveyor she's not sure.
On 5/18/22 at 10:25 a.m. Surveyor observed R15 in bed on her back. Surveyor observed there is now a mat on the floor along the left side of R15's bed and the call light is now within reach.
On 5/18/22 at 10:33 a.m. Surveyor asked LPN (Licensed Practical Nurse)-J if R15 should have a mat on both sides of the bed. LPN-J replied yes.
On 5/18/22 at 3:01 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R18) of 1 Residents reviewed for weight loss maintained acce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R18) of 1 Residents reviewed for weight loss maintained acceptable parameters of nutritional status.
*R18 had a severe weight loss of 16.3% or 20.2 pounds from 3/15/22 to 4/17/22 (34 days). The facility did not weigh R18 for 3 days from admission or on a weekly basis per policy and procedure.
Findings Include:
Surveyor reviewed the facility Weighing and Measuring the Resident policy and procedure revised 3/21 and notes the following:
Purpose
The purposes of this procedure are to determine the Resident's weight and height, to provide a baseline and an ongoing record of the Resident's body weight as an indicator of the nutritional status and medical condition of the Resident in order to determine the ideal weight of the Resident.
Documentation
The following information should be recorded in the Resident's medical record:
1. Date and time the procedure was performed.
2. The name and title of the individual(s) who performed the procedure.
3. The height and weight of the Resident.
4. All assessment data obtained during the procedure.
5. How the Resident tolerated the procedure.
6. If the Resident refused the procedure, the reason(s) why and the intervention taken.
7. The signature and title of the person recording the data.
R18 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Low Back Pain, Osteoporosis, and Pressure Ulcer of Sacral Region. R18 is her own person.
R18's admission Minimum Data Set (MDS) dated [DATE] documents R18's Brief Interview for Mental Status (BIMS) score to be 15 indicating R18 is cognitively intact for daily decision making. R18's MDS also documents that R18 requires extensive assistance of 2 for bed mobility, transfers, dressing, and toileting.
R18's comprehensive care plan has a focused problem of inadequate oral intakes due to acute illness, infection, as evidenced by poor oral intakes with low blood sugars, altered mentation, need for IV antibiotic, oral nutritional supplement.
Initiated 3/18/22
All interventions are dated 3/18/22 except for 5/17/22 the care plan was updated to provide glucerna as ordered.
On 5/18/22 R18's care plan was updated by Dietician (RD-F) after discussion with Surveyor to include the intervention to encourage R18 to allow staff to weigh her, re-approach R18 as needed following refusal/declining to be weighed.
Surveyor notes that R18's physician orders document R18 to be weighed weekly on Sunday, one time a day every Sunday effective 3/20/22.
Surveyor reviewed R18's Treatment Administration Records (TARS) and notes the following:
March-R18 should have been weighed on 2 Sundays of the month and was not.
3/20/22-no weight
3/27/22-no weight
April-out of 4 Sundays, R18 was only weighed 2 times, on 4/17/22 and 4/24/22
4/3/22-no weight
4/10/22-no weight
May-out of 3 Sundays prior to start of survey, R18 was not weighed 2 times and on 5/1/22 it is recorded that R18 was weighed however, no weight is recorded
5/1/22-no weight recorded
5/8/22-no weight
5/15/22-no weight
Surveyor reviewed R18's Nutrition/Dietary progress notes:
3/18/2022 15:47 Nutrition/Dietary Note Text: MNT: Nutrition admission Assessment
admission following hospitalization for general weakness, poor appetite r/t polypharmacy & opioid use, IVF, chronic low back pain, GERD, type II DM, hypoglycemia, hyponatremia Pertinent medications: Omeprazole, Aspirin, Eliquis, Furosemide for edema, Glimepiride, Quetiapine, Duloxetine, B12, probiotic, Melatonin, FerroSul, calcium citrate, NaCl, MgOx, MVI
Current diet order: CCHO
Supplement: 4 oz Magic Cup TID w/meals, 30cc Active Critical Care once daily
CBW 124.2#, ht 60, BMI 24.3; hospital wt = 126#
Hgb A1c 12/17/21 = 4.9%
Has unstageable pressure area to coccyx measuring 5.0 x 3.8 x 2.5cm.
Based on CBW her estimated nutritional needs are 1680-1960 cal and cc fluid (x30-35cal and cc/kg), 78-112 gm protein (x1.4-2.0 gm/kg)
Resident's po intakes variable based on her level of alertness. She is receiving IV ABT for wound infection. Since admission her blood sugars have been running low which may have been affecting her mentation. MD wrote order for IVF dextrose solution 100cc/hr continuous, 1200cc fluid restriction was d/c'd. Her blood sugars continue to run low despite receiving IV dextrose solution. Glimepiride was d/c'd as well. Resident has order for Magic Cup w/meals which she likes, order in place for Active Critical Care once daily to assist with healing. IDT met with resident's family re: POC, talked about poor po intakes, appetite stimulant. Family was in favor of obtaining order for appetite stimulant. Nursing to communicate same to MD for order. Blood sugars are being checked every hour. CCHO diet in place. Order place for snacks TID between meals.
PES: Inadequate oral intakes r/t acute illness, infection AEB poor po intakes w/low blood sugars, altered mentation, need for IV ABT, oral nutritional supplement. Provide CCHO diet as ordered, provide Magic Cup and Active Critical Care as ordered. Proceed to POC.
Surveyor noted R18 has magic cup with meals and active critical care 1x daily in place
Snacks 3x daily between meals was added, Appetite stimulant was recommended for R18
3/22/2022 12:12 Nutrition/Dietary Note Text: NAR: Resident po intakes variable from poor to good. Blood sugars much improved, IV dextrose d/c'd 3/20 later afternoon. Currently not receiving any oral agents. Blood sugars ranging from 111-230. Continue to receive CCHO diet. Receiving Remeron 15mg daily for appetite. For wound healing, has order for Magic Cup TID w/meals, 30cc Active Critical Care once daily = 21gm additional protein, and Juven 1pkg BID. Has order for snacks TID between meals.
Surveyor noted R18 is now receiving Remeron 15 mg daily for appetite. No other changes since 3/18/22.
4/1/2022 15:22 Nutrition/Dietary Note Text: NAR: Blood sugars remain better than during initial admission. Receiving snacks 3 times daily from facility and family. Continues to receive IV ABT x 2 for wound infection. Wound vac in place to coccyx area. Appetite remains variable from poor to fair. CCHO diet and multiple nutritional supplements in place for healing. Continues to take Remeron 15 mg for appetite. Resident has frequently declined to be weighed. Continue to monitor as needed.
Surveyor notes it is documented that R18 frequently declines to be weighed, however, there is no documentation of R18's refusals to be weighed or the approaches taken to encourage R18 to be weighed.
4/5/2022 11:01 Nutrition/Dietary Note Text: NAR: D/c meeting held with resident, resident's family and IDT this morning. Discussed current nutritional status, priority of wound healing. Family was updated on current nutritional supplements given for wound healing, discussed improved blood sugars, bowel management. Family stated that resident has been consuming Magic Cup and will offer her an additional serving between meals. Discussed constipation in light of pain medication she is receiving along with limited physical movement and poor to fair po intakes. Discussed trying power pudding BID and prune juice once daily along with adding Glucerna @ breakfast. Resident needs much encouragement to sit up in bed or sit in chair at meals, tolerates 20 minutes or less each time 2* pain. At this time, recommend 1/4 cup power pudding BID and 8 oz Glucerna once daily @ breakfast. POC reviewed and updated.
Surveyor noted Magic cup to be offered to R18 between meals. Recommended 1/4 cup power pudding 2x daily and 8 oz glucerna 1x daily at breakfast.
Surveyor notes R18's physician orders document the above changes, however, R18's care plan was not updated.
4/18/2022 12:40 Nutrition/Dietary Note Text: NAR: Resident weighed 4/17 = 104#, re-weight = 104#, admission wt 3/15 = 124.2#. Resident declined to be weighed during stay until yesterday. Significant wt loss of 16.3% since admission. Her po intakes have been poor to fair since admission, at times, better. Has order for 15mg Remeron daily for appetite. Current BMI = 20.3, low for age. Has stag IV pressure injury to coccyx, please refer to nursing note 4/14/22 14:06. Continues to have orders for Magic Cup TID, Juven BID, Active Critical Care once daily, Glucerna once daily w/breakfast, power pudding BID. Resident hasn't been tolerating sitting up in chair for meals. Eats meals in bed, family assists at meals daily. At this time, family has not decided whether to pursue alternative feeding method for nutrition. Hospice information has been provided to family. Wt loss related inadequate oral intakes, increased needs for wound healing, failure to thrive status. Resident remains responsible party. MD notified of CBW and wt loss, response pending. Resident asleep at this time to review wt, wt loss. Continue to monitor.
R18 has a severe weight loss of 16.3% since admission, (from 3/15/22 of 124.2 pounds to 104 pounds on 4/17/22).
Hospice information has been provided to family in regards to R18.
4/18/2022 14:19 Nutrition/Dietary Note Text: Resident up in w/c at this time with family visiting. Writer updated resident re: CBW and weight loss. Resident stated that she wanted to lose weight. Writer discussed increased nutritional needs for wound healing, that her intakes have been minimal compared to what's needed for healing. Resident stated that she has been eating a lot more than she did at home. Writer discussed the option of PEG tube feedings to assist with meeting her needs, discussed risks and benefits of having PEG tube. Resident stated that it wasn't worth going through major surgery and the increased risks of infection to have tube placed. Resident stated that she did not want to have PEG tube feedings. She stated that she would continue to try to eat more snacks and eat more at meals. Magic Cup w/meals and oral nutritional supplement once daily w/breakfast to remain in place. Continue to monitor.
Surveyor noted a PEG tube was discussed with R18, but R18 declined.
5/17/2022 10:44 Nutrition/Dietary Note Text: NAR: CBW 5/16 = 110.8#, wt slowly increasing which is favorable, wt 4/17 = 104#. PO intakes poor fair which has been her usual, good at times. Continues to receive CCHO diet w/thin liquids, tolerating diet consistency adequately. Her blood sugars much improved since admission. Recent labs 5/6 Hgb A1c = 6.0% which is favorable in light of T2DM (type 2 diabetes diagnosis) dx. Stage IV to coccyx showing improvement, remains on Juven BID, Active Critical Care once daily along with Magic Cup w/meals and Glucerna once daily. No recommendations at this time. Continue with diet and oral nutritional supplements as ordered. POC reviewed.
Surveyor notes that R18's weight is improving.
On 5/18/22 at 10:12 AM, Surveyor interviewed RD-F in regards to R18 and the weight loss of 16.3% since admission. RD-D states that R18 does not always take the supplements and R18 takes awhile to consume R18's meals. R18 is eating poor to fair, about 0-15% of the meals. Surveyor asked RD-F about R18's weights not being completed. At the time of this interview, RD-F pulled up R18's physician orders and stated there were no orders for R18 to be weighed and will have to put in an order for weekly weights. RD-F stated that R18 definitely should have been weighed weekly from admission due to R18's frail condition. RD-F stated weekly weights is per policy and procedure. RD-F stated that R18 would refuse to be weighed and confirmed at this time that R18's refusals to be weighed is not documented. RD-F also confirmed there is no documentation that attempts were made to re-approach R18 to be weighed when R18 refused. RD-F also agreed with Surveyor that R18's refusals to be weighed was not documented on R18's care plan and should have been with R18 centered interventions to encourage R18 to be weighed.
On 5/18/22 at 3:07 PM, Surveyor shared the concern with Director of Nursing(DON-B) and Administrator(NHA-A) of R18 having weight loss and not getting weighed per policy and procedure.
On 5/19/22 at 7:47 AM, DON-B stated that the expectation is a Resident is weighed for the first 3 days after admission on the same shift, and then weekly on Sundays.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility did not ensure 1 (R1) of 1 sampled Residents received respirato...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility did not ensure 1 (R1) of 1 sampled Residents received respiratory care and services in accordance with professional standards of practice and Resident's plan of care.
R1's oxygen (O2) was observed to not be running according to physician's orders.
Findings Include:
Surveyor reviewed the facility's Verbal Orders policy and procedure revised 2/14 and notes the following:
Policy Statement
1. Verbal orders shall only be given in an emergency or when the Attending Physician is not immediately available to write or sign the order.
2. Verbal orders will always be based on verbal exchange with the prescribing practitioner or on approved written protocols.
The facility also provided a Telephone Orders policy and procedure revised 2/14
Policy Interpretation and Implementation
1. Verbal telephone orders may only be received by licensed personnel. Orders must be reduced to writing, by the person receiving the order, and recorded in the Resident's medical record.
R1 was admitted to the facility on [DATE] with diagnoses of Chronic Diastolic Heart Failure, Cerebrovascular Disease, Dysphagia, Type 2 Diabetes Mellitus, Cirrhosis of Liver, Chronic Kidney Disease, and Major Depressive Disorder. R1 is his own person.
R1's admission MDS dated [DATE] documents R1's BIMS score to be a 6, indicating R1 demonstrates severely impaired skills for daily decision making. R1 requires limited assistance for bed mobility, and extensive assistance for toileting, transfers, dressing, and hygiene. Surveyor notes that R1 was admitted on O2 but it is not documented on the MDS. The MDS documents that R1 is receiving hospice services.
Surveyor reviewed R1's comprehensive care plan and notes the following:
R1 has Congestive Heart Failure
Initiated 5/2/22
Intervention: O2 settings: O2 via nasal cannula @ 2 Liters (L) continuous
Initiated 5/2/22
Surveyor reviewed R1's hospital Discharge summary dated [DATE] and notes the following:
Continue with nasal O2, now requiring 4L O2.
However, R1's physician orders provided to Surveyor dated 5/6/22 state: O2@2L/min per nasal cannula as needed to keep pulse OX +90%.
On 5/16/22 at 10:32 AM, Surveyor observed R1 sitting in R1's wheelchair by their bed. Concentrator is located across the room and the O2 tubing is not marked and dated. Surveyor observed the O2 tubing on floor behind R1's wheelchair. R1 stated the O2 tubing will reach to the bathroom. During the interview, Surveyor observed R1 having some respiratory distress, some gasping for air. Surveyor observed the O2 to be set at 4L.
On 5/16/22 at 11:52 AM, Surveyor observed R1 in bed and appears to be comfortable with head of bed elevated.
On 5/16/22 at 1:40 PM, Surveyor observed R1's O2 tubing now dated with 5/16/22. Visitor at bedside informed Surveyor that hospice and the doctor ordered for the O2 to be at 5L. Surveyor observed the setting at 5L.
On 5/17/22 at 10:46 AM, Surveyor notes that per hospice note dated 5/16/22, R1's O2 was increased to 5L prn. Surveyor notes there is no current physician order documenting the O2 change.
On 5/17/22 at 1:55 PM, Surveyor spoke to Director of Nursing (DON-B) in regards to R1's O2 expected setting as there was some discrepancy in the expected setting. Surveyor explained that according to the visitor at R1's bedside, R1's O2 liters had been changed from 2L to 5L by hospice on 5/16/22. DON-B stated that if the liters of O2 has been changed, this should be reflective in R1's current physician orders. Surveyor shared the concern that if O2 change had been communicated to the facility that the change in O2 did not get documented on R1's physician orders to reflect 5 liters. DON-B understood the concern that if a nurse reads the current physician orders of 2L, may potentially change R1's O2 setting down to 2L.
On 5/17/22 at 2:50 PM DON-B provided documentation of the physicians's order that was received today for the increase in O2 liters from 2L to 5L. DON-B understood the concern that the new O2 order should have been entered when the hospice nurse communicated the change in the O2 setting. DON-B informed Surveyor that hospice had communicated the O2 liter change to Registered Nurse(RN-E).
The facility provided Surveyor with documentation that the O2 order had been changed to specify that R1's O2 setting was to be at 5L/min per Nasal Cannula.
On 5/17/22 at 3:05 PM, Surveyor shared the concern with DON-B and Administrator(NHA-A) in regards to R1's physician orders stating O2@2L, however, the hospital discharge summary stated O2@ at 4L and Surveyor observed R1's setting to be at 4L and 5L. DON-B informed Surveyor that RN-E has been re-educated.
On 5/18/22 at 12:05 PM, Surveyor observed R1's O2 set at 4L and R1 appeared to be restless. RN-E confirmed the O2 setting is at 4L. Surveyor asked RN-E why is R1's setting at 4L if 5/17/22 the order was received for 5L . RN-E stated that hospice was in today (5/18/22) and brought R1's O2 back down to 4L but does not know why hospice made the change.
On 5/18/22 at 12:32 PM, Surveyor informed DON-B of the O2 change that hospice made.
On 5/18/22 at 3:07 PM, Surveyor again shared the concern with DON-B and NHA-A of R1 not having O2 set at liters not according to what the facility orders were. No further information was provided at this time.
On 5/19/22 at 9:04 AM, Surveyor interviewed Hospice Registered Nurse(HRN-I) in regards to R1's O2 setting. HRN-I stated that HRN-I did not make a change to R1's O2 setting and informed Surveyor that it is up to facility staff to determine where the O2 setting should be at.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure hospice services was effectively coordinated for 2 (R1 & R15) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure hospice services was effectively coordinated for 2 (R1 & R15) of 3 sampled Residents receiving hospice services. This included the communication process, obtaining a physician order, and agreed upon hospice documentation in the medical record.
*R1 was admitted on hospice on [DATE] and had no physician order for hospice services. R1's medical record did not contain a hospice plan of care, election form, physician certification of terminal illness and the names and contact information for hospice personnel involved in R1's hospice care.
*R15 was admitted on hospice on [DATE] and R15's current physician orders did not have an order for hospice services.
Findings Include:
Surveyor reviewed the facility's Hospice Program policy and procedure revised 7/17 and notes the following:
Policy Interpretation and Implementation
5. Hospice providers who contract with the facility:
b. Are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility.
8. In general, it is the responsibility of the hospice to manage the Resident's care as it relates to the terminal illness and related conditions, including the following:
a. Determining the appropriate hospice plan of care
b. Changing the level of services provided when it is deemed appropriate
c. Providing medical direction, nursing and clinical management of the terminal illness
d. Providing spiritual, bereavement and/or psychosocial counseling and social services as needed
e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms
9. In general, it is the responsibility of the facility to meet the Resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual Resident needs.
d. Communicating with the hospice provider(and documenting such communication) to ensure that the needs of the Resident are addressed and met 24 hours per day.
11. Our facility staff to coordinate care provided to the Resident by our facility staff and the hospice staff.
a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for Residents receiving these services.
b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the Resident and the family.
c. Ensuring that the facility communicates with the hospice medical director.
d. Obtaining the following information from hospice:
1. The most recent hospice plan of care specific to each Resident
2. Hospice election form
3. Physician certification and recertification of the terminal illness specific to each Resident
4. Names and contact information for hospice personnel involved in hospice care of each Resident.
5. Instructions on how to access the hospice's 24-on-call system
6. Hospice medication information specific to each Resident
7. Hospice physician and attending physician orders specific to each Resident
12. Coordinated care plans for Residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility in order to maintain the Resident's highest practicable physical, mental, and psychosocial well-being.
13. The coordinated care plan will reflect the Resident's goals and wishes, as stated in his or her advance directives and during ongoing communication with the Resident or representative, including:
a. Palliative goals and objectives
b. Palliative interventions
c. Medical treatment and diagnostic tests
14. The coordinated care plan shall be revised and updated as necessary to reflect the Resident's current status.
1.) Surveyor reviewed the facility/hospice service agreement specific to R1 dated [DATE] and notes the following applicable to R1.
-Hospice Plan of Care means an individualized written plan of care established, reviewed and revised by the Interdisciplinary Team(IDT)
Responsibilities of Hospice
admission to Hospice Program
-Hospice shall maintain adequate records of each authorization of Hospice admission.
Hospice Plan of Care
Establishment of Hospice Plan of Care. In accordance with applicable federal and state laws and regulations, Hospice shall establish and maintain a written Hospice Plan of Care in consultation with Nursing Facility representatives. All hospice care provided must be in accordance with the Hospice Plan of Care. The Hospice Plan of Care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. The Hospice Plan of Care must reflect the participation of Hospice, Nursing Facility, and the patient and family to the extent possible.
Review of Hospice Plan of Care
Shall be review, revise, and document every 15 calendar days.
Coordination of Services
The Hospice designee is responsible for providing overall coordination of the hospice care with Nursing facility representatives and communicating with Nursing Facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the Resident.
Manner of Communication
Communication between Hospice nurse and Nursing facility's primary nurse will be at each visit and via telephone as needed. Hospice's coordinator will document the interaction in the hospice patient medical record.
Physician Orders
All physician orders communicated to Nursing Facility on behalf of Hospice in connection with the Hospice Plan of Care will be in writing and signed by the applicable attending physician or hospice physician. Hospice will maintain adequate records of all physician orders communicated in connection with the Hospice Plan of Care.
Compilation of Records
Nursing facility and Hospice shall each prepare and maintain complete, correct and detailed clinical records concerning each Resident receiving Hospice care. Each such record shall be readily available on request by an authorized federal, state, or local government or regulatory agency.
R1 was admitted to the facility on [DATE] with diagnoses of Chronic Diastolic Heart Failure, Cerebrovascular Disease, Dysphagia, Type 2 Diabetes Mellitus, Cirrhosis of Liver, Chronic Kidney Disease, and Major Depressive Disorder. R1 is his own person.
R1's admission MDS (minimum data set) dated [DATE] documents R1's BIMS (brief interview of mental status) score to be a 6, indicating R1 demonstrates severely impaired skills for daily decision making. R1 requires limited assistance for bed mobility, and extensive assistance for toileting, transfers, dressing, and hygiene. Hospice is documented on R1's MDS.
On [DATE] at 1:37 PM, Surveyor reviewed R1's hospice binder located at the nurse's station. Surveyor was unable to locate a hospice plan of care, no service contract signed by R1 or Hospice election form, Physician certification of the terminal illness, and the names and contact information for hospice personnel involved in R1's hospice care .
Surveyor reviewed R1's current physician orders and noted there is no hospice order for evaluation and treatment.
Surveyor reviewed R1's facility care plan and notes the following:
R1 has a terminal prognosis
Initiated [DATE]
Interventions initiated on [DATE] with no updates
Encourage support system of family and friends
Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near.
Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.
Work with nursing staff to provide maximum comfort for the resident.
On [DATE] at 2:44 PM, Director of Nursing (DON-B) informed Surveyor that hospice services was already coordinated for R1 from the hospital and stated there should be an order for hospice services on R1's current physician orders. Surveyor shared that R1 has no current hospice order.
DON-B stated that hospice was already coordinated to be on hospice from the hospital, but there should have been an order.
[DATE] 03:05 PM Surveyor met with DON-B and Administrator(NHA-A) and shared the concern there was no hospice order. DON-B provided an order for hospice care dated [DATE].
On [DATE] at 8:58 AM, Surveyor reviewed R1's hospice binder again. Surveyor notes a plan of care that was not available on [DATE] or [DATE] is now located in the binder.
Surveyor noted there is still no service contract signed by R1, no Hospice election form, no Physician certification of the terminal illness, and no names and contact information for hospice personnel involved in R1's hospice care.
Surveyor reviewed the hospice plan of care and notes it is not integrated with the facility plan of care.
On [DATE] at 9:01 AM, Surveyor asked Registered Nurse(RN-E) where the hospice schedule was. RN-E was unable to locate a schedule of hospice visits for R1. RN-E informed Surveyor the facility is not aware of when a Certified Nursing Assistant(CNA) comes in to help with cares for R1.
On [DATE] at 3:07 PM, Surveyor shared the concern with DON-B and NHA-A that hospice services have not been coordinated between the facility and hospice services for R1 and R1's hospice binder is missing documented information per regulation. No further information was provided at this time.
Surveyor reviewed documentation concerning R1's hospice care. Surveyor notes on [DATE] at 3:10PM it is documented Call back from (name of hospice) RN at this time: (R1) change of condition update given by writer with a request for hospice nurse visit in AM. Surveyor notes there is no documentation that a hospice nurse came in to visit on [DATE].
Surveyor reviewed R1's Hospice visit record and notes on [DATE] at 10:15 AM, is the last sign in for a hospice provider.
On [DATE] at 8:59 AM, Health Services Manager (HSM-D) informed Surveyor that R1 had expired at approximately 5:00 PM on [DATE]. Surveyor informed HSM-D that Surveyor was unable to locate the 'Notice of Removal of a Human Corpse From a Facility'. HSM-D stated, Will have to call hospice to locate the form.
On [DATE] at 9:04 AM, Surveyor interviewed the Hospice Registered Nurse (RN-I) designated as R1's case manager. RN-I stated the hospice binder is completed on admission with all the necessary paperwork. RN-I stated RN-I is the main contact. RN-I confirmed RN-I was at the facility on [DATE] at about 11:30 AM. Surveyor notes that RN-I did not sign in on R1's visit record.
RN-I stated the expectation is that all disciplines put in their documentation of visits at the time of visit. RN-I stated, We have leeway being a hospice provider.
On [DATE] at 10:35 AM, HSM-D provided the 'Notice of Removal of a Human Corpse From a Facility' form and stated HSM-D had to request it from hospice. HSM-D informed Surveyor that HSM-D recalls the nurse and CNA being in the facility on [DATE] to see R1 and does not know why they did not sign in. HSM-D stated there is not regular communication from the hospice staff, only if there is an issue.
On [DATE] at 11:02 AM, Surveyor again shared the concern of the missing required documentation from hospice concerning R1 with NHA-A and DON-B. Both NHA-A and DON-B understood the concern and no further information was provided at this time.
2.) R15's diagnoses includes hypertension, atrial fibrillation, Parkinson's disease and dementia with behavioral disturbances.
The annual MDS (minimum data set) with an assessment reference date of [DATE] is checked for hospice while a resident.
A care plan was initiated on [DATE] & revised on [DATE] for the resident has a terminal prognosis and is receiving hospice services from [name of hospice].
The nurses note dated [DATE] documents [name of hospice] nurse [name] RN (Registered Nurse) is here and assessed resident, res (resident) refused assessment. Writer also notified [name of hospice nurse], res. cont (continues) to refused meds (medication) and at times meals, and cares and weights, specially today's weight, will re approach. Needs met and anticipated, call light within reach.
Surveyor reviewed the hospice binder for R15 and noted the last hospice note is dated [DATE].
On [DATE] at 10:00 a.m. Surveyor reviewed R15's physician's orders and was unable to locate any hospice orders.
On [DATE] at 3:18 p.m. during the end of the day meeting with Administrator-A and DON (Director of Nursing)-B Surveyor informed staff Surveyor was unable to locate a hospice order for R15.
On [DATE] at 9:31 a.m. Surveyor asked DON-B if there is any information regarding R15's hospice order. DON-B informed Surveyor the order is in there now. DON-B explained R15 went to the hospital in [DATE] and when R15 was readmitted the hospice order was not put in. DON-B indicated hospice continued but they should of had an order. Surveyor asked DON-B since [DATE] there hasn't been a hospice order for R15? DON-B replied correct. Surveyor asked DON-B when a Resident is readmitted does anyone review the orders. DON-B informed Surveyor in the morning clinical review they review the discharge summary but they don't go over the resident's previous orders.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not have an updated comprehensive assessment for repositioni...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not have an updated comprehensive assessment for repositioning/assist bars for 10 (R18, R234, R1, R17, R2, R23, R6, R9, R15 & R25) of 10 Residents observed with repositioning/assist bars. Further, the facility did not have evidence of the Interdisciplinary Team (IDT) involvement, no documentation of repositioning/assist bars being reviewed at care conference, and repositioning/assist bars were not documented on their Minimum Data Set (MDS) or comprehensive care plan.
*R18, R234, R1, R17, R2, R23, R6, R9, R15, and R25 did not have a physician order for their repositioning/assist bars and the facility did not obtain consent or assess the risk of entrapment prior to installation. Their electronic medical record (EMR) did not have evidence that risks and benefits were discussed with the Resident and/or representative.
Findings Include:
Surveyor reviewed the facility's Proper Use Bed Assistive Device policy and procedure revised 12/16 and notes the following:
Policy:
Bed assistive devices will be assessed on an individual basis.
Bed assistive devices will only be applied if manufactured for the specific bed.
Facility does not use bedrails, siderails, or safety rails.
Procedure:
1. If a Resident and/or responsible party requests a bed assistive device, Physical Therapy(PT) and/or nursing will assess, and the Registered Nurse(RN) manager will monitor the Resident's cognitive and functional ability for use.
2. If an assessment shows the Resident's ability is appropriate, the bed assistive device will be attached to the bed.
3. An assessment will be done quarterly, with a change of condition, and annually to determine if use of the bed assistive device continues to be appropriate.
1.) R18 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Low Back Pain, Osteoporosis, and Pressure Ulcer of Sacral Region. R18 is her own person.
R18's admission Minimum Data Set(MDS) dated [DATE] documents R18's Brief Interview for Mental Status (BIMS) score to be 15 indicating R18 is cognitively intact for daily decision making. R18's MDS also documents that R18 requires extensive assistance of 2 for bed mobility, transfers, dressing, and toileting. Bed rail is not documented on R18's MDS.
On 5/16/22 at 10:38 AM, Surveyor observed 2 repositioning bars located on R18's bed. At 10:46 AM, R18 informed Surveyor that R18 does not use the repositioning bars.
Surveyor was unable to locate an assessment for repositioning bars in R18's medical record.
Surveyor notes that repositioning bars are not documented in R18's comprehensive care plan.
Surveyor notes there is no physician order for R18's repositioning bars.
2.) R234 was admitted to the facility on [DATE] with diagnoses of Acute Bronchitis and Nontraumatic Hematoma of Soft Tissue. R234 is her own person.
Surveyor notes R234's 5/13/22 admission MDS is in progress dated 5/13/22. A BIMS was completed on 5/9/22 and R234 has a score of 15 indicating R234 is cognitively intact for daily decision making.
On 5/16/22 at 10:28 AM, Surveyor observed 2 repositioning bars located on R234's bed.
On 5/18/22 at 8:45 AM, R234 informed Surveyor that R234 does not use the repositioning bars.
Surveyor was unable to locate an assessment for repositioning bars in R234's medical record.
Surveyor notes that repositioning bars are not documented in R234's comprehensive care plan.
Surveyor notes there is no physician order for R234's repositioning bars.
3.) R1 was admitted to the facility on [DATE] with diagnoses of Chronic Diastolic Heart Failure, Cerebrovascular Disease, Dysphagia, Type 2 Diabetes Mellitus, Cirrhosis of Liver, Chronic Kidney Disease, and Major Depressive Disorder. R1 is his own person.
R1's admission MDS dated [DATE] documents R1's BIMS score to be a 6, indicating R1 demonstrates severely impaired skills for daily decision making. R1 requires limited assistance for bed mobility, and extensive assistance for toileting, transfers, dressing, and hygiene. Bed rail is not documented on R234's MDS.
On 5/16/22 at 10:32 AM, Surveyor observed R1 had 1 repositioning bar on left side of R1's bed.
Surveyor was unable to locate an assessment for repositioning bars in R1's medical record.
Surveyor notes that repositioning bars are not documented in R1's comprehensive care plan.
Surveyor notes there is no physician order for R1's repositioning bars.
On 5/17/22 at 11:25 AM, Director of Nursing(DON-B) stated that therapy does an assessment for repositioning bars and should be in the Resident's chart.
On 5/17/22 at 1:54 PM, Surveyor informed DON-B that Surveyor could not find assessments for the R18, R234, and R1. DON-B indicated they would check with therapy to see if they have the assessments. DON-B stated the facility has been back and forth with who is doing the assessments.
On 5/17/22 at 2:41 PM, DON-B stated that all Residents in the facility have the repositioning bars on their beds. We use them for the remotes, call lights, and sometimes for positioning. We do not have assessments for any of the Residents for the repositioning bars.
On 5/17/22 at 3:04 PM, Surveyor shared the concern with Administrator(NHA-A) and DON-B that R18, R234, and R1 did not have a completed assessment for their repositioning bars. Surveyor also shared there is no documentation that risks and benefits were explained to the Resident and there was no documentation of the repositioning bars on R18, R234, and R1's care, and there was no physician's order for the repositioning bars. No further information was provided at this time.
On 5/18/22 at 11:46 AM, the facility provided an undated siderail assessment for R18, R234, and R1.
On 5/18/22 at 3:07 PM, Surveyor again shared the concern with DON-B and NHA-A of R18, R234, and R1 not having an assessment for the repositioning bars including documentation that risks and benefits were acknowledged by R18, R23, and R1. DON-B confirmed the assessments provided by the facility were completed after Surveyor addressed the concern of no assessments for R18, R234, and R1. No further information was provided at this time.
7.) R6 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease and Glaucoma.
On 5/17/22 R6's Quarterly Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score to be 3 indicating R6 has severe cognitive impairment. R6's MDS also documents that R6 requires extensive assistance of one for bed mobility. Bed rail is not documented on R6's MDS.
On 05/17/22 at 2:34 PM R6 was observed sleeping in bed with the left repositioning bar up.
On 5/17/22 R6's medical record was reviewed and an assessment for repositioning bars was not found in R6's medical record.
On 5/17/22 R6's care plan was reviewed and a care plan for repositioning bars was not found in R6's care plan.
On 5/17/22 R6's physician orders were reviewed and no orders for repositioning bars were found in R6's medical record.
On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R6's repositioning bars.
The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided.
8.) R17 was admitted to the facility on [DATE] with diagnoses of Anxiety and Osteoarthritis.
On 5/17/22 R17's Quarterly Minimum Data Set (MDS) dated [DATE] documents R17's Brief Interview for Mental Status (BIMS) score to be 12 indicating R17 has mild cognitive impairment. R17's MDS also documents that R17 requires supervision with assistance of one for bed mobility. Bed rail is not documented on R17's MDS.
On 05/16/22 at 9:54 AM R17 was observed sleeping in bed with a repositioning bar up on the left side of the bed.
On 05/17/22 at 10:54 AM R17 was observed sleeping in bed with a repositioning bar up on the left side of the bed.
On 05/18/22 at 8:55 AM R17 was observed sleeping in bed with a repositioning bar up on the left side of the bed.
On 5/17/22 R17's medical record was reviewed and an assessment for repositioning bars was not found in R17's medical record.
On 5/17/22 R17's care plan was reviewed and a care plan for repositioning bars was not found in R17's care plan.
On 5/17/22 R17's physician orders were reviewed and no orders for repositioning bars were found in R17's medical record.
On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R17's repositioning bars.
The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided.
9.) R23 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Mild Cognitive Impairment.
On 5/17/22 R23's Significant Change in Status Minimum Data Set (MDS) dated [DATE] documents R23's Brief Interview for Mental Status (BIMS) score to be 0 indicating R23 has severe cognitive impairment. R23's MDS also documents that R6 requires extensive assistance of two for bed mobility. Bed rail is not documented on R23's MDS.
On 05/17/22 at 2:57 PM R23 was observed in bed with both repositioning bars up.
On 5/18/22 at 8:48 AM R23 was observed in bed with both repositioning bars up.
On 5/17/22 R23's medical record was reviewed and an assessment for repositioning bars was not found in R23's medical record.
On 5/17/22 R23's care plan was reviewed and a care plan for repositioning bars was not found in R23's care plan.
On 5/17/22 R23's physician orders were reviewed and no orders for repositioning bars were found in R23's medical record.
On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R23's repositioning bars.
The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided.
10.) R25 was admitted to the facility on [DATE] with diagnoses of Aphasia and history of Stroke.
On 5/17/22 R25's Quarterly Minimum Data Set (MDS) dated [DATE] documents R25's Brief Interview for Mental Status (BIMS) score to be 3 indicating R25 has severe cognitive impairment. R25's MDS also documents that R25 requires extensive assistance of two for bed mobility. Bed rail is not documented on R25's MDS.
On 05/16/22 at 2:31 PM R25 was observed in bed with both repositioning bars up.
On 5/17/22 at 3:00 PM R25 was observed in bed with both repositioning bars up.
On 5/17/22 R25's medical record was reviewed and an assessment for repositioning bars was not found in R25's medical record.
On 5/17/22 R25's care plan was reviewed and a care plan for repositioning bars was not found in R25's care plan.
On 5/17/22 R25's physician orders were reviewed and no orders for repositioning bars were found in R25's medical record.
On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R25's repositioning bars.
The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided.
4.) R2's diagnoses includes hypertension and hemiplegia and hemiparesis following cerebral infarction affecting right dominate side
The quarterly MDS (minimum data set) with an assessment reference date of 4/30/22 documents a BIMS (brief interview mental status) score of 00 which indicates severe impairment. R2 requires extensive assistance with one person physical assist for bed mobility and under the physical restraint section bed rails is coded as not used.
On 5/16/22 at 3:28 p.m. Surveyor observed R2 propelling self in a wheelchair in her room. Surveyor observed there is a transfer bar up on left side of bed.
On 5/17/22 at 7:30 a.m. Surveyor observed R2 awake in bed on her back. Surveyor observed the transfer bar on the left side of R2's bed is up.
Surveyor reviewed R2's paper and electronic record and was unable to locate an assessment for R2's left transfer bar.
On 5/17/22 at 3:34 p.m. Surveyor asked RN (Registered Nurse)-K where Surveyor would be able to locate side rail/transfer bar assessments. RN-K informed Surveyor he doesn't know if there is an assessment.
On 5/17/22 at 3:50 p.m. Surveyor informed DON (Director of Nursing)-B Surveyor is unable to locate an assessment for the transfer bar on R2's bed and asked DON-B to provide Surveyor with any information.
On 5/18/22 at 8:22 a.m. Surveyor observed R2 in bed on her back with a left transfer bar up.
On 5/18/22 at 3:01 p.m. Surveyor informed Administrator-A and DON (Director of Nursing)-B Surveyor was unable to locate an assessment for R2's left transfer bar.
On 5/19/22 Surveyor reviewed the left transfer bar assessment for R2 dated 5/17/22.
5.) R9's diagnoses includes multiple sclerosis and obesity.
R9's annual MDS (minimum data set) with an assessment reference date of 2/10/22 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R9 requires extensive assistance with two plus person physical assist for bed mobility and under the physical restraint section bed rails is coded as not used.
On 5/16/22 at 11:13 a.m. Surveyor observed R9 in bed on her back with the head of the bed elevated. Surveyor observed two padded quarter side rails up on the bed.
On 5/17/22 at 7:36 a.m. Surveyor observed R9 in bed on her back with the head of the bed elevated and two padded quarter side rails up on the bed. Surveyor asked R9 if she uses the side rail. R9 replied sometimes and explained she holds onto them to pull herself over in bed.
On 5/18/22 at 10:30 a.m. Surveyor observed R9 in bed on her back with the head of the bed elevated and two padded quarter side rails up on the bed.
Surveyor reviewed R9's paper and electronic record and was unable to locate an assessment for R9's padded quarter side rail.
On 5/17/22 at 3:34 p.m. Surveyor asked RN (Registered Nurse)-K where Surveyor would be able to locate side rail/transfer bar assessments. RN-K informed Surveyor he doesn't know if there is an assessment. RN-K explained they assess the mattress on R9's bed but not the bars specifically as not every bed has bars.
On 5/17/22 at 3:50 p.m. Surveyor informed DON (Director of Nursing)-B Surveyor is unable to locate a side rail assessment for R9's padded side rails and asked DON-B to provide Surveyor with any information.
On 5/19/22 Surveyor reviewed the side rail assessment for R9 dated 5/17/22.
6.) R15's diagnoses includes hypertension, atrial fibrillation, Parkinson's disease and dementia with behavioral disturbances.
The annual MDS (minimum data set) with an assessment reference date of 4/8/22 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R15 requires extensive assistance with two plus person physical assist and under the physical restraint section bed rails is coded as not used.
On 5/16/22 at 10:17 a.m. Surveyor observed R15 in bed on her back with the head of the bed elevated. Surveyor observed there is are two transfer bars up.
On 5/16/22 at 3:31 p.m. Surveyor observed R15 in bed. Surveyor observed there are two transfer bars up on R15's bed.
On 5/17/22 at 7:33 a.m. Surveyor observed R15 in bed asleep. Surveyor observed there are two transfer bars up on R15's bed.
On 5/18/22 at 8:25 a.m. Surveyor observed R15 in bed on her back with two transfer bars up on R15's bed.
Surveyor reviewed R15's paper and electronic record and was unable to locate an assessment for R15's bilateral transfer bars.
On 5/17/22 at 3:34 p.m. Surveyor asked RN (Registered Nurse)-K where Surveyor would be able to locate side rail/transfer bar assessments. RN-K informed Surveyor he doesn't know if there is an assessment.
On 5/17/22 at 3:50 p.m. Surveyor informed DON (Director of Nursing)-B Surveyor is unable to locate an assessment for the transfer bars on R15's bed and asked DON-B to provide Surveyor with any information.
On 5/18/22 at 3:01 p.m. Surveyor informed Administrator-A and DON (Director of Nursing)-B Surveyor was unable to locate an assessment for R15 transfer bars
On 5/19/22 Surveyor reviewed the left transfer bar assessment for R15 dated 5/17/22.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected most or all residents
Based on interview and record review the facility did not ensure they completed COVID-19 testing of staff according to Center for Disease Control (CDC) recommendations for 1 of 3 staff with approved n...
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Based on interview and record review the facility did not ensure they completed COVID-19 testing of staff according to Center for Disease Control (CDC) recommendations for 1 of 3 staff with approved non-medical exception for the COVID-19 vaccination.
There is no documentation Staff-L, who has a non-medical COVID-19 vaccination exemption, is being tested for COVID-19 according to CDC county transmission rates. This has the potential to affect all 35 Residents at the facility.
Findings include:
On 5/18/22, this Surveyor reviewed the facility policy titled Resident and Staff Testing Intervals for COVID-19, undated, which documents: Staff not up to date (COVID-19 vaccination) must routine test at a minimum according to CDC county transmission rate.
1. High to Substantial High (Rate)-2 times per week;
2. Moderate (Rate)-1 time per week
3. Low (Rate)-not recommended.
On 5/18/22, this Surveyor reviewed the facility staff vaccination tracking log. Three staff with non-medical vaccination exceptions were reviewed. Staff-L had an approved non-medical COVID-19 vaccination exemption. Staff L's testing records were reviewed and no COVID-19 testing could be found from 3/26/22 to 5/18/22. Staff-L started employment with the facility on 9/21/21.
On 5/18/22, the CDC county transmission rate for Milwaukee county was reviewed for the timeframe of 3/26/22 to 5/13/22. The county was documented to be in moderate or high spread for the entirety of that time, indicating Staff-L should have been tested for COVID-19 either 1 or 2 times per week.
This Surveyor reviewed Staff-L's work scheduled during the time of 3/26/22 to 5/18/22. The facility schedule documented Staff-L worked on both resident living units for a total of 18 shifts.
On 5/18/22, at 1:45 PM, Director of Nursing (DON)-B was interviewed and indicated that no documentation could be found that Staff-L was tested for COVID-19 between 3/26/22 and 5/18/22 and he should have been.
The above findings were shared with Nursing Home Administrator-A and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM. Additional information was requested if available. None was provided.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 17 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $99,452 in fines. Extremely high, among the most fined facilities in Wisconsin. Major compliance failures.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Eastcastle Pl Bradford Ter Conv Ctr's CMS Rating?
CMS assigns EASTCASTLE PL BRADFORD TER CONV CTR an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Wisconsin, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Eastcastle Pl Bradford Ter Conv Ctr Staffed?
CMS rates EASTCASTLE PL BRADFORD TER CONV CTR's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 51%, compared to the Wisconsin average of 46%.
What Have Inspectors Found at Eastcastle Pl Bradford Ter Conv Ctr?
State health inspectors documented 17 deficiencies at EASTCASTLE PL BRADFORD TER CONV CTR during 2022 to 2025. These included: 1 that caused actual resident harm and 16 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Eastcastle Pl Bradford Ter Conv Ctr?
EASTCASTLE PL BRADFORD TER CONV CTR is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 40 certified beds and approximately 39 residents (about 98% occupancy), it is a smaller facility located in MILWAUKEE, Wisconsin.
How Does Eastcastle Pl Bradford Ter Conv Ctr Compare to Other Wisconsin Nursing Homes?
Compared to the 100 nursing homes in Wisconsin, EASTCASTLE PL BRADFORD TER CONV CTR's overall rating (5 stars) is above the state average of 3.0, staff turnover (51%) is near the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.
What Should Families Ask When Visiting Eastcastle Pl Bradford Ter Conv Ctr?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Eastcastle Pl Bradford Ter Conv Ctr Safe?
Based on CMS inspection data, EASTCASTLE PL BRADFORD TER CONV CTR has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Wisconsin. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Eastcastle Pl Bradford Ter Conv Ctr Stick Around?
EASTCASTLE PL BRADFORD TER CONV CTR has a staff turnover rate of 51%, which is about average for Wisconsin nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Eastcastle Pl Bradford Ter Conv Ctr Ever Fined?
EASTCASTLE PL BRADFORD TER CONV CTR has been fined $99,452 across 16 penalty actions. This is above the Wisconsin average of $34,073. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Eastcastle Pl Bradford Ter Conv Ctr on Any Federal Watch List?
EASTCASTLE PL BRADFORD TER CONV CTR is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.