an 4? a Communication Resu}t Report Nov, 1. 2916 I ij?y '3 Date/Timef Nov: 7. 2016 Page .File No. Mode Destination Pg[s} Rasult Not Sent 5302 Memory TX ?16082646340 P. 35 OK Reason for error E.1) Hang up or line fail No answer E. E. 5) Exceeded max. E?mail size NORWOOD HEALTH CENTER COUNTYHUMAHSERVICES 1500 H. Chasmutdvmo Mmh?nl?, 119154449 Thom: 715-334?1138 Fax: 915334165 FAX Date: 31-1?1 0 gages: . Vow Attn: MS (7 Faci?ty: Fax: meg? me: Ashley Voiowek, APSW avoin?rsalfco?womlmims Phnus: 715.334.2183 3235 chfmienix: um?eq" mm NOTICE: maymg?j'm ?cslm?a Wham tannin m?mmlin?maa?m belonging In the: swing which ?9 min?umn?mis mm m?yfm??wm of?u: individual. mm?tymud above. Ifznm mmut 11m inland-=5 are: husky noif?ad that mydimiomn, nagging. dishibu?m, nrlhu raking ofmy aclim hmlianccm the mu??unlixl shio?y 11mm. 11? ynuilmm remide mum ih mar, planm?nmemmiy mt?rfy us mmga?nr mm 0mm original inns. 3-: Ef?gy-?ag} I NORWOOD HEALTH CENTER WOOD COUNTY HUMAN SERVICES 1600 N. Chestnut Avenue Marshfield, WI 54449 Phone: 715?384?2188 Fax: 715?389-2266 Eek FAX TRANSMISSION Date: \Lf-Ll ,10 it Pages: Attn: Facility: Fax: ll?i?i? From; Ashley Volovsek, APSW Phone: 715.384.2188 3236 avolovsek@co.wood.wi.us Comments owe? CONFIDENTIAL NOTICE: The documents accompanying this facsimile transmittal letter content con?dential information belonging to the sender, which is legally privileged. The informa?on is intended only for the use of the individual or entity named above. Ifyou are not the intended recipient, you are hereby noti?ed that any disclosure, copying, distribution, or the taking of any action in reliance on the contents of this con?dential information is strictly prohibited. Ifyou have received this facsimile transmittal letter in error, please immediately notify us by telephone to airange for the retinal of the original to us. Thank you. . la i 8:888 DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance STATE OF WISCONSIN DHS Wis. Admin. Code Page 1 of8 (Rev. D4110) MISCONDUCT INCIDENT REPORT $552.5: Euranntiusmu Lit-.1335 Use this form to report incidents of alleged misconduct (client abuse or neglect or misappropriation of client property) and injuries of unknown source. The Department reviews this report to determine whether further investigation of the incident is warranted. So that the Department may make this determination, please complete the Misconduct incident Report in its entirety. Use the following information as guidance when completing this form. ENTITY INFORMATION (Page 3) The entity or facility named is the entity reaponsible for the care of the affected person. The Department will send all responses regarding the report to the entity reporter and address listed in this section. ENTITY TYPE CODES Code Entity Type Code Entity Type 34 Emergency Mental Health Service Programs 105 Personal Care Agency 40 Mental Health Day Treatment Services for Children 124 Hospitals 61 Outpatient Community Mental Health/Dev. Disabilities 12? Rural Medical Centers 63 Community Support Programs 131 Hospices 75 Community Substance Abuse Services (CSAS) 132 Nursing Homes 82 Certi?ed Adult Family Homes 133 Home Health Agencies 83 Community Based Residential Facilities 134 Facilities for Persons with Developmental Disabilities 88 Licensed Adult Family Homes 000 Other (Specify) 89 Resident Care Apartment Complexes SUMMARY OF (Pages 3 and 4) Indicate when the incident occurred. Include the month, day, year, and time of the incident 08959003, 10:30 AM). If you do not know the exact day, provide an approximate date the week of March 1, the month of March, between March 1 and April 15). If you give approximate dates, explain how you determined the dates. Briefly describe the incident. Summarize the incident in the space provided, even if more details or documents are attached. Describe the effect of the incident upon the affected person or the person?s reaction to the incident. if a person has been physically injured, describe the injury, the size of the bruise, etc. A photograph of the injury is very helpful. If photographs are taken, identify whenthe photos were taken, how many were taken and by whom. Describe any indication or expressions of pain, anger, frustration, humiliation, fear, etc. by the person during or after the incident. Explain what the entity did, upon learning of the incident, to protect the person(s) from further potential misconduct. Describe the steps that the entity took to protect the person(s) from subsequant potential episodes of misconduct while a determination on the matter is pending. indicate the accused person's current employment status and date of any employment action alter the alleged incident. NOTE: The entity is not required to terminate the employment of an accused person to meet protection requirements. Check the specific location where the incident happened. if the incident happened at a location other than the entity, indicate the speci?c address of that location. AFFECTED PERSON INFORMATION (Page 4) include the affected person?s name, date of birth, gender, address, and telephone number. If the affected person has been adjudicated incompetent, is under age 18, or has an authorized Power of Attorney for Health Care, include the name, address, and telephone number of the parent, guardian, or legal representative. IV. ACCUSED PERSON INFORMATION (Page 4) include the accused person's name (if known), social security number, position or title at the time of the incident, date of birth, gender, current home address, and home telephone number. Entities must inform the accused person that a report regarding the incident is being tiled with the appropriate authority. If the accused person is currently employed by an entity other than the reporting entity, include the name, address, and telephone number of the current employer. If the accused person is under age 18, provide the name, address, and telephone number of a parent or guardian. If there is more than one accused person, complete this section for each person. V. LAW ENFORCEMENT INVOLVEMENT (Page 5) . Check if law enforcement was contacted or is involved. Indicate the of?cer's name, department, address, telephone number, and?if available ?the case number. Attach a copy of the law enforcement incident report, if available. VI. PERSONS WITH SPECIFIC KNOWLEDGE OF THE (Page 5) include all persons with speci?c knowledge of the incident. Include the person's name, gender, address, and telephone number. Check whether the person is an entity employee. include the person?s position at the entity or relationship to the affected person. Attach additional pages, as necessary. are (RSV. 1 far?n11. age 2 of 8 Vii. DESCRIBE OR ATTACH A COPY OF THE INVESTIGATIVE RECORDS CONCERNING eagle, 6) Provide all relevant Information found during the entity's internal investigation, including the following: STAFF INFORMATION CLIENT INFORMATION 9 Accused individuai?s personnel records, including but not limited 9 Pertinent medical records, including but not limited to the person?s to training records, disciplinary records, time cards or sheets for plan of care or treatment plan at the time of the incident. the period during which or date(s) the incident occurred- Ambulance run report! if applicable. Wllness time Cards 0" Sheen? forthe E339?0d datelsl the a Any relevant hospital admission and discharge documents. moment 006mm" I I a Photographs of visible injuries or affected property. a Start schedule, roster, or assignment sheets for the time period a Financial account Statements includin account numb and or date(s) the incident occurredbalance information. a tatements from the accused to us! and Witnesses re ating Statements about the incident- the moldent. a Sign?off sheets indicating completion of cares pertinent to the LAW ENFORCEMENT Incident Law enforcement of?cer?s narrative reports. INFORMATION Photographs - Entity?s policies and procedures related to the incident. Photographs and diagram or illustration of the scene where the OTHER INFORMATION incident occurred with relevant information included, Any Other records that may locations of witnesses, client, and pertinent objects at the time of the incident. PERSON PREPARING THIS REPORT (Page 6) Provide the name, position or title, and telephone number of the person preparing this report. The person preparing this report must sign and date this form in the space provided. IX. WRITTEN STATEMENT (Page 7) Ask the affected client, the accused person, and all other persons with information about the incident to provide written statements. if the entity uses its own forms to obtain written statements about the incident, the entity may attach those forms to the incident Report. If the entity attaches its own written statements to the report form, the facility should ensure that each person completing a written statement provides the identifying information requested on the report form and signs the statement. a The entity is advised to follow up on written statements by asking probing questions to gather as much detail as possible, including what happened, how the incident happened, when it happened, where it happened, reactions at the time of the incident, and other witnesses who may have been present. It is suggested that the entity use the FOLLOW UP QUESTIONS (Page 8) following the written statement form as a guide when questioning the accused person. 9 - is misstatement; mama FEDERALLY CERTIFIED NURSING HOMES AND FEDERALLY CERTIFIED INTERMEDIATE CARE FACILITIES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES Upon the completion of the entity's internal investigation of the incident, send the completed form, any available documentation, and the results of your investigation within 5 WORKING days (Monday Friday, excluding legal holidays) of the date the entity knew or should have known of the incident. - ALL OTHER ENTITIES Upon the completion of the entity's internal investigation of the incident, send the completed form, any available documentation, and the results of your investigation within 7 CALENDAR days of the date the entity knew or should have knovvn oi the incident. . . 7, NOTE: All complaints regarding both credentialed staff RN, LPN, MDland non credentialed staff nurse aides, personal care workers, housekeepers) will be tracked by the Department of Health Services, Division of Quality Assurance (DOA). DQA will refer complaints that involve credentialed staff to the Department of Regulation and Licensing for investigation. Send the completed form and any supporting documentation to: Department of Health Services Division of Quality Assurance Office of Caregiver Quality PD. Box 2969 Madison, WI 53701-2969 You may also send forms via: E?mail: Fax: (608)264?6340 I eraser oussnons THE-S FORM TO (608) 254-3319. STATE OF DHS Wis. Admin. Code Page 3 of 8 DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance (Rev. 04110) MISCONDUCT INCIDENT REPORT Completion of this form is required by DHS Wis. Admin. Code. Failure to tile 3 complete and accurate report of an incident of alleged misconduct, as required, may subject the entity to forfeiture or other sanctions speci?ed by the Department under DHS Wis. Admin. Code, and may delay the investigation process. Personal information will be used to investigate the reported incident and the resuits of the investigation may be shared with other authorized investigative agencies. This report form must he completed in its entirety. Additional information may be attached. TYPE OR PRINT NEATLY iN BLACK I. unruly Egalitarian Name Entity or Facility Telephone Number NORWOOD HEALTH CENTER Street Address County Federal Provider or Certi?cation No. 1600 CHESTNUT AVE WOOD 52A460 City State Zip Code State License, Approval, or Registration No. MARSHFIELD WI 54449 5027 Name Administrator I Entity Type Code (See instructions.) JORDON BRUCE 132 ii?f'is antimalwa 1N DICATE when the incident occurred. If the exact date and time are Date Occurred Date Discovered Time Occurred unknown, make a reasonable estimate and indicate that the date and time are estimated. include the date the incident was discovered, it other than 106274016. 8 PM 103 L16 the date the incident occurred. BRIEFLY DESCRIBE THE INCIDENT in the space below. Summarize the incident here even if additional documentation is attached. C.N.A Arlene pier indicted to supervisor Maria Lupke RN on 106 L16 1 lam that she witnessed RN Rosemary Carlson pull resident - hair while speaking inappropriate verbal language to him during cares on 10?27?2016 at 8PM. DESCRIBE THE EFFECT that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident. Resident - assessment indicates no physical effects from alleged hair pulling incident. any staff who have harmed him. his highly impaired cognition due to a traumatic brain injury. He is unable to Verbalize effects, RN cannot recall the incident nor verbalize C.N.A Arlene Dampier appears emotionally upset by incident. RN Rosemary Carlson denies incident occurred does not appear to have effects. No other witnessed identi?ed. figs {5 gm ff? (Rev- 04l'10) is i; Page 4 of 8 EXPLAIN what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct. Ensured safety of all residents, immediately suspended involved staff pending investigation, Education to all staff immediately on reporting per policy, Phone call interviews to all staff members working 10/27?10/3 1 inquiring potential indicators of safety conCerns, verbal nonverbal treatment of residents by staff or suspicions of inappropriateness, All LTC residents surveyed for safety, inquires of witnessing any staff being mean/verbal or abusive towards themselves or others CHECK the specific location where the incident happened. At Your Entity During Transport El Another Location Explain: Ill. AFFECTEDT PERSON INFORMATION If more than one, include additional pages, Name? Affe Date of Birth Se?x .. . I Male Female Telephone Number cted Person Aess' 1600 CHESTNUT AVE - .- . City State zip Code MARSHFIELD 54449 if the affected person is adjudicated incompetent or under ?18, or has an authorized Power of Attorney for Health Care, include the name, address, and telephone number of parent, guardian, or legal representative. Name - Parent, Guardian, or Power of Attorney Telephone Number State Zip Code .2 - N. ACCUSED PERSON if more than one, include additional pages; Name Accused Persian (if known) Social Security Number ROSEMARY CARLSON Position or Title or Relationship to Affected Person {at the time of the incident) Sex Date of Birth RN El Male Female List any known credential held by the accused at time of the incident; El credentialed Staff Resident RN, LPN, social worker, security guard, professional counselor. Credentialed Staff Other; RN Home Telephone Number .-.H . . City State Zip Code NOTE: If employer is other than the reporting entity, provide information about accused person?s current employer. Name - Employer Sex Telephone Number El Male Female I State Zip Code Street Address City NOTE: if accused person is under 18, provide paren?s) or guardian information. or Guardian sex Telephone Number Male DFemale City State Zip Code Street Address Fs2447 (Rev. 04? 0) Page 5 of 8 V. LAW ENFORCEMENT st Was iaw enforcement contacted or involved? No Yes If ?yes,? complete the following. Attach a copy of the law enforcement incident report, if available. Name - Of?cer (it available) Department OFFICER KRAMER POLICE DEPARTMENT Street Address Case Number (if available) 110W IST ST 16-16486 City State Zip Code Tetephone Number MARSHFIELD WI 54449 71 5 ?3 84?3 1 13 V1. SPECIFIC KNOWLEDGE OF THE INCIDENT If more space is necessary, attach additional pages. Name Person who REPORTED incident to the Entity Sex ARLENE DAMPER Mate Female I Telephone Number Street Address is this person an ENTITY Cit State Zip Code 1 Yes [3 N0 Pesiti'0n in the Entity or Reiationship to the Affected Person CNA Name - Person with lnformationAbout the incident Sex IORDON BRUCE Mate El Femate Address Telephone Number 1600 CHESTNUT AVE 7153844188 City State Zip Code is this person an ENTITY WI 54449 El Yes El No Position in the Entity or Relationship to the Affected Person Name - Person with information About the Incident S'ex ELIZABETH MASAN 13 Male Female Address Telephone Number 1600 CHESTNUT AVE 715?3 84?2188 City State Zip Code is this person an MARSHFIELD WI 544449 Yes No Position in the Entity or Relationship to the Affected Person DIRECTOR OF NURSTN Name Person with information Ab0ut the incident Sex MARIA LUEPKE Male Female Address Telephone Number 1600M CHESTNUT AVE 715~384?2188 City State Zip Code Is this person an ENTITY MARSEFIELD WI 54449 Yes [3 No Position in the Entity or Relationship to the Affected Person HEAD NURSE Name - Person with Information About the incident Sex ASHLEY VOLOVSEK Cl Mate Female Address Teiephone Number 1600 N. CHESTNUT AVE 715% 8442188 City State Zip Code is this person an MARSHFIELD WI 54449 Yes No Position in the Entity or Relationship to the Affected Person SOCIAL WORKER (Rev. 04MB) BELOW. Ii PLEASE SEE ENCLOSED Page 6 of8 ?rms. ?r?m'a?gt?uy- 134g.) Name Person Preparing This Report ASHLEY VOLOVSEK ENTITY Yes No Position in the Entity or Relationship to the Affected Person SOCIAL WORKER Street Address 1600 N. CHESTNUT AVE City MARSHFIELD WI State Zip Code 54449 Email Address SIGNATURE Person Preparing This Report Telephone Number 715?3 84?2188 Date Signed it ~qu (Rev. 04l10) Page 7 of 8 Ix. WRITTEN STATEMENT Use this page to collect written statements from the accused person, affected person. and witnesses regarding incidents of alleged misconduct (abuse or neglect or misappropriation of property). Make additional copies of this page as necessary. Completion of this form is voluntary. it is suggested that entities ask the questions on the foitowing page to obtain additional information and detail about reported incidents. Piease record all responses given. Entities may use their own forms; however, any written statement [mist be attached and submitted with the Misconduct incident Report (DOA form Section 1 a To be completed by Entity Brief Description of Alleged incident ?Marion R?s broken arm," "the theft of Marion R?s credit card,? "Marion R?s felt?) Section 2 To be compieted by Accused Person, Affected Person, or Witness Full Name (Last, First, Middle initial) Home Teiephone Number Street Address Work Telephone Number City State Zip Code Position or Title or Relationship to the Affected Person Section 3 To be completed by Accused Person, Affected Person, or Witness Provide as much information as you know about the incident described above. Tell what you know about the incident in detail. Use additional pages, as needed. [3 Check if additional pages are included. Accused Person. Affected PersonI or Witness Date Signed (Rev. 04/10) Page 8 of 8 FULLOW UP QUESTRONS TO BE ASKED BY THE ENTITY It is suggested that entities ask the following questions to obtain additional, detailed information about reported incidents. Please record all reSponses in the space provided. Attach additional pages, information, documentation, diagrams, photographs, or other evidence as appropriate, Check if additional pages are included. Check if items or documents are attached. Check if a photocopy of an item or document is attached. El Check if an item or document is being retained by the entity; describe where and how it is being stored pending the outcome of this investigation. How do you know about the above incidenthappen to you? Did you see it? Did another person tell you of it? if so, who? Time and date of the incident. When did it happen? When did you ?rst learn about it? Location. (Where did the incident occur? Where were you when it happened? If others were present, who and where were the others? Where were you when you learned about it or saw it? Describe the location. Attach a diagram.) Was anyone else present when it happened, you learned about it, or when you saw it? if so, who? Where was each person? Did you teii anyone about the incident? if so, what did you tell them, who did you tell and when did you tell them? What did the person say, if anything? Was anyone harmed in any way (physically or sexually, emotionally or mentally, or ?nancially) or could someone have been harmed? if so, describe the harm or potential harm. a Were others harmed in any way? if so, identify the person who was harmed and describe the harm- Describe the affected person?s actions or reactions during the incident including statements made, changes in demeanor, or other indications of pain, fear, sadness, anger, humiliation, etc. Describe the actions or reactions of others who observed or were involved in the incident. at For Affected Persons: Did you tell anyone about what happened to you? if so, who did you tell and when and where did you tell them? a For Other Witnesses: is or was the affected person able to report or talk about the incident? if so, did the affected person say anything to you? If so, what? Describe the way that the affected person acted when telling you about the incident. a To your knowledge, did the affected person tell anyone else? if so, who and when? Are there others who know or may know about the incident? if so, who are they and why do you think they have informatiOn about the incident? Do you have or are you aware of any evidence, documentation or information that may be relevant to the incident? (Examples: photos, diagrams, maps, receipts, video tapes, audio tapes, medical records, care plans, ?nancial transaction records, etc.) if so, What is it and where is it? Additional information Name Person interviewed Name - Person Conducting the interview - interview Date 1 1 ?1?2016 1 105 Statement Rosemary Carlson RN Rosie does not recall anything unusual occurring on 10/27 or 10/28 PM shifts. No incidents that she can recall while giving suppositories. . was no more combative that always hits. Rosie state she Resident if has never pulled a resident?s hair. On Thursday, was working with Arlene or Carlie, not sure struck out, Rosie told him not to, did it again and asked to step While stopping his hand. Asked him Why he hits .. replied ?because?. Rosie then administered suppository. Never pulled hair, never said anything about pulling hair. Rosemary denies all allegations. She states she is mysti?ed why she was called with suspension and reasons given. Rosie informed of report to law enforcement potential fulther investigation. Norwood to contact Rosie when investigation is complete, Rosie is on no contact with building/peers except Administration. Involved parties: Page 1 of 2 incident 1027?2016 resident, Rosemary Carlson RN, Arlene Dampier CN, Ancillary staff: Jordon Bruce-Administrator, Elizabeth Masanz DON, Maria Luepe Head Nurse/supervisor, Ashley Volovsek SW r' a Incident: On Sunday 10/30 PM shift, C.N.A Arlene Dampier sent supervisor Maria an email as she wanted to discuss something with Maria. Maria received email Monday morning met with Arlene Monday 10l3l at 1100. As per report of Arlene Dampier: Thursday, 1047?2016 about 8PM C.N.A Arlene Dampier and RN Rosemary Carlson were in residerz isa2 out Rosie to act like a 2 year old, I?ll treat you like one aadpulled is usually combative with cares, Rosie responded to 35.25:: room administering rectal suppository as Person aans?r/rollfar cares. was in bed. Arlene reports she witnessed- 3137' R0353 ?5 ?Stop hitting me and Rosie reached it?ll her right hand and Pulled hair in the tOPWOHI/bangs area. Sla?fumed Over: administered supposiioij/ (is they rolled him back. -lciclced Rosie, Rosie replied ?If you want hair again. Rosie then turned to Arlene and stated ?That?s what you do, you pull hair so thee is no bruises as Rosie instructed Arlene not to tell anyone. Arlene was suspended pending investigation 85 escorted out of building 10l31/16 1110 by Maria RN. Arlene instructed not to disclose any im?brmation to any staff except Police, Admin, DON, HRN SW as part of investigation. Jordon w? Admin updated 1120, 1200 SW Ashley completed online report of potential abuse to DHS. Marshfield Police Department was called 1400. Of?cer Landon Karamer assigned to investigation case it 16?16486, he came to Norwood 1415 to speak with Maria RN regarding incident. Dr. Espada, treaunent director was informed of situation by Liz, DON. About 1200, Maria RN called Rosemary to inform she?s been suspended pending an investigation needs to report to Norwood 11l1/ 16 1100 for a meeting with Jordon called updated by Maria Ashley 1250 11/1/16 1100 Rosemary was interviewed by Jordon, Liz Maria. Rosie could not recall anything unusual occurring on or Friday PMs. here was no incident that occurred during suppository to She denied pulling. - hair, denied any statements related to accusation. Coat: i a a 6 'il) uting Factors: .has sustained a Traumatic Brain Injury from MVA 1?2?16 while ?eeing from police. - 1 a has history of mood liability (suicide attempts, ADHD, drug/alcohol addiction) has impaired cognition due to TBI status; memory de?cits, impaired thinking . diSplays behaviors due to history/T131 status, is combative with cares has an extensive legal history including disorderly conduct, aggression/violence, sexual - misconduct Page 2 of 2 9 Education initiated to all staff immediately before working ?oor 9 Education at Unit meeting 10/31/16 on reporting per policy a Mandatory Training scheduled on reporting abusefneglect per Norwood policy scheduled facility Wide for November 2016. 9 Phone call interviews to all staff members working 10/27-10/31 inquiring potential indicators of safety concerns, verbal 85 nonverbal treatment of residents by staff or suspicions of a All residents surveyed on both units (Crossroads Pathways) for safety, inquires of witnessing any staff being meanfverbal or abusive towards themselves or others a Initiated Audit to ensure staff comply with understating appropriate policies Conclusion: It is uncertain if caregiver misconduct occurred. a ha?? capacity ?50 ROBE/remember incident. He indicated a few staff members are mean, but could not name or describe any further. He denied any staff pulling his hair. When asked if he feels safe here, he replies ?Yes?. When asked if he is afraid of living here, he replied When asked if he is Worried someone will hurt him, he replied little?. RN assessment of 'd not reveal any signi?cant ?ndings (hair pulling). -has care plans in place for behaviors. Rosie RN denies allegations which Arlene Dampier C.N.A stated occurred 10627?16 8PM during cares. No other Witnesses are identi?ed. sirens . Veins/1, New xiv?3 ?12 em Ashley Voidisek, Date CC: Jordan Bruce, Admin Liz Masa'nz, DON Maria Luepke, I-IRN lO?31~l6 1 100 Arlene Dampier C.N.A Arlene approached RN Maria Monday 10?3 1-16 1100 to report information. Arlene stated on Th y, lO~27~16 PM shift about 8PM, she was assistin Rosemary Carlson RN turn resident over in bed to administer suppository. I. was combative hit Rosie, Rosie replied ?Stop hitting me? and reached her right hand up to forehead and pulled hair. Rosie 85 Arlene tinned John oVer, administered suppository, and then rolled in bed. kicked Rosie; Rosie replied ?If you?re going to act like a 2 year old, I?ll treat you like one? and pulled hair again. As Rosie was walking out of the room, she said to Arlene ?That?s What you do; you pull hair so there?s no bruises?. Rosie then told Arlene not to tell anyone. Wmar happier: (4&5 Wm warmer Ashley Volovsek' From: laurieerkens@dhs.wisconsin.gov Sent: Monday, October 31, 2016 1:02 PM To: Ashley Volovsek Subject: Alleged Nursing Home Resident Mistreatment Report Thank you for submitting an Alleged Nursing Home Resident Mistreatment Report to the DHS Division of Quality Assurance (DQA). Upon completion of the facility's investigation and within 5 working days of the date discovered, submit a completed Incident Report (13?62447) to the DQA Of?ce of Caregiver Quality. Questions about reportijlg requirements or investigation status may be directed to the DQA Of?ce of Caregiver Quality at gov or 608261-8319. SURVEY RESPONSES 1. Facility Name Norwood Health Center 2. State License Numb er 5027 3. Street Address 1600 N. Chestnut Ave 4. City Marsh?eld 5. County WOOD 6. Zip Code 54449 Date Occurred 10/28/2016 8. Time Occurred (include AM or PM) 8 PM 9. Date Discovered 1 DB 1f2016 10. Allegation Type Abuse 1. Resident?s Name 12. Name of accused Rosemary Carlson 13. Title ofjaceused (nurse aide, nurse, caregiver, resident, family, stranger, etc.) RN 14. Summary of Incident Initial reports indicate staff witnessed potential situation of abuse of a resident by staff 15. Person Preparing Report Ashley Volovsek 16. Email Address 17. Phone Number 715?384~2188 Survey Results Page 1 0f 3 :f A??eged [Merging Heme Ree?t?emt M?gtreatmeet Repert User Infermat?en Name: Anonymous Email: Levitation: Company: Position: 1&3 Address: 66.170.71.51 Started: 10/31/2016 10:57:05 AM Compieted: 10/31/2016 11:01:47 AM Time Spent $222125?$8??5?bsm?i?222id?82 Custom 1= Cuetem 2: Custom 3: WA 1.. Facility Name Norweo?? Health Center 2. State License Number 5027 3., Street Add ress 1600 N. Chestnut Ave 4. City Marsh?eld 5. County WOOD 6., Zip Code 54449 1 Date Occurred 10/28/2016 1 H1 1 . .l-r-?r?rn in I how T?r?x f1 f1 1 u? 1 nIni Inn1 Survey Results Page 2 of 3 8? Time Occurred (include AM or PM) 8PM 9? Date Discovered 10/31/2016 10. Allegatlon Type Abuse 11 . Resident?s Name 12. Name of accused Rosemary Carlson 13.. Title of accused (nurse aide, nurse, caregiver, resident, family, stranger, etc.) RN 14. Summary of Incident Initial reports indicate staff witnessed potential situation of abuse of a resident by staff 15.. Person Preparing Report Ashley Volovsek 15. Email Address avolovsek@co.wood.wi.us 17. Phone Number 715884-2188 Ant?dln?dl HA 1 - .m-r-rn In - Survey Results Page 3 of 3 u; . n-x-rvn - In - - - Irma/:1 DEL- 1 nm 1 mm .C