PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 000 INITIAL COMMENTS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 000 Surveyor: 28910 On 9/18/12, Surveyors 28910 and 10902 made an unannounced visit to Bella Vista RCAC in Oshkosh, WI to conduct 4 complaint investigations and a standard survey. Surveyor 10902 returned to the facility to conduct an additional complaint investigation on 12/5/12 and additional information was gathered through 12/19/12. As a result of this process, 5 citations were issued and 2 of the 5 complaints were substantiated. U 115 89.23(2)(a)1. SERVICES U 115 SUFFICIENT SERVICES. Minimum required services. In this paragraph, "capacity to provide" means that the facility is able to provide the minimum required services to any tenant who needs or develops a need for those services. This Rule is not met as evidenced by: Surveyor: 28910 Based on record review and interviews, the facility failed to provide the necessary services to meet the needs for Tenant/Resident 1 when Tenant 1 could not regain entrance to the locked facility on 1/13/11 causing Tenant 1 to break a window of the facility entrance door in an attempt to escape the cold and enter the facility. Findings include: For long term care providers, a plan of correction is required for class A, B, & C violations. TITLE (X6) DATE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 8LQD11 If continuation sheet 1 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 115 Continued From page 1 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 115 Tenant 1 was admitted to the facility on 1/31/09. A pre-admission assessment was completed which included information that Tenant 1 had mild dementia, was a very pleasant person, and liked to consume beer "socially". On 9/18/12, Surveyor 28910 conducted an interview with House Manager B, who stated after Tenant 1's admission, Tenant 1's mental capabilities began declining caused by his dementia. House Manager B stated that because of his mental decline there were necessary changes made to the level of staff supervision/cares for Tenant 1. She stated his behaviors and agitation gradually increased and "he would go out drinking and come back (to the facility) drunk and upset." House Manager B stated, "You couldn't talk to him when he got upset." She further stated that when he went out of the facility he would frequently not have his "swipe card" (key card which allowed him access back into the locked facility after hours). House Manager informed Surveyor of a night when Tenant 1 could not get into the facility because he did not have his swipe card and he threw something at the glass window to get in. Surveyor 28910 reviewed the "Resident Incident Report" referencing an event that occurred at 11:50 PM on 1/13/11. The report noted that Tenant 1 "took a tripod stand from front entrance and slammed it into front door shattering glass door in an effort to get in door." Caregiver C provided a written statement that she observed Tenant 1 pounding on the door with the tripod and noticed that the glass was broken. Caregiver C noted that she let Tenant 1 in and wrote, "(Tenant 1) had a lot to drink that night." Maintenance D provided a written statement which noted that he came upon Caregiver C and Tenant 1 in the front For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 2 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 115 Continued From page 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 115 lobby and observed the broken door glass. Maintenance D described that Tenant 1 was screaming and demanding, subsequently calmed down, and then became upset again. Maintenance D wrote, "I asked (Tenant 1) where his key card was and he stated he didn't have one. ... (Tenant 1) appeared to be intoxicated and was assisted to his room by (Caregiver C). ... It should be noted that when I initially reported to work I did check the resident sign out/in log and (Tenant 1) was not listed as being out... This type of incident could be avoided in the future if: 1. (Tenant 1) would remember to keep his key card with him or 2. (Tenant 1) would sign out. ..." Per review of Tenant 1's "Risk Agreement" signed upon 1/31/09 admission, the agreement noted, "Resident will check in/out when leaving facility due to fire safety/fire drill needs and for resident's safety and security." Surveyor reviewed e mail correspondence between Tenant 1's family and administration and e mail correspondence between facility administrative staff regarding the 1/13/11 incident and noted the following: - POA E, in an e mail to (former) Administrator K dated 1/19/11, wrote, "... I understand that while there is a sign-in/out procedure at Bella Vista, it is not strictly enforced and adhered to by the staff . On this particular occasion, (Tenant 1) had announced his plans for the evening to the front desk attendant, who did not request that (Tenant 1) sign out. ... I would like to know why the attendant on duty at the time of (Tenant 1's) departure did not inform the incoming attendant of his whereabouts. I understand that there have been previous occasions when (Tenant 1) has overlooked the sign-out process either through For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 3 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 115 Continued From page 3 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 115 lack of consistent enforcement of the policy by management, failure to remind residents of this requirement, or forgetfulness on his part. ...". - (Former) Administrator K, in an e mail to his superior dated 1/27/11, wrote, "...the fact that we don't have a Security guy at the desk any longer, they (family members) may challenge me, 'How was dad supposed to get in? He forgot his swipe pad, there is no one at the desk, it is cold, he doesn't have a cell phone, etc!' The Accucom call system in the foyer (location where Tenant 1 was attempting to enter through) is not functioning... I should have a plan B of how he (others) get in after hours if he forgets swipe card and no one at front desk. ..." During an interview with House Manager B on 9/18/12, House Manager B acknowledged facility awareness of Tenant 1's changing cognitive and emotional condition and drinking behaviors prior to the 1/13/11 incident. The Incident Report documentation and staff statements verified that Tenant 1 was locked out of the facility and no one was present to let him in when he arrived; Tenant 1 broke a glass window attempting to regain entry to the facility. (Former) Administrator K acknowledged the call system at the front door was not functioning and there was not an effective entry system for residents who returned after the facility has been secured and who may have forgotten their swipe card. The facility failed to provide the necessary services to meet the need for Tenant 1 to promptly enter the secured facility upon his return home. Cross Reference: 0171- Annual Review 0211- Risk Agreement For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 4 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 154 89.25(3) SCHEDULE OF FEES FOR SERVICES. PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 154 A copy of the schedule of fees for services shall be given to each prospective tenant and to the prospective tenant's family or designated representative, where appropriate, along with pub-lic information materials on assisted living if provided by the department. Copies of revised fee schedules shall be provided to current tenants and their families or representatives, where appropriate, at least 30 days in advance of an increase in fees. This Rule is not met as evidenced by: Surveyor: 28910 Based on record review and interview, facility failed to provide Tenant/Resident 1/family representative (POA E) a revised fee schedule at least 30 days in advance of increases in fees when in February through August 2009 Tenant 1's rates increased by $100 (possibly increased utility charges), when in September, 2009 rates increased by $620 (possibly a level of care increase), and again on 1/25/11 when rates increased by $25 (an annual percentage increase). Findings include: Per Surveyor 28910 review of the "Residency Agreement between Tenant 1 and the facility, there were typed rental rates crossed off and the following was handwritten in the contract, "$2300 plus $80 Med (medication) set-up monthly. $2380 per month Includes continental breakfast, 1 meal daily, weekly housekeeping, flat linen service, monthly nursing assessment, water, sewer, For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 5 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 154 Continued From page 5 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 154 maintenance repairs. (Cable phone heat and utilities separate)." The contract also noted, "1. Bella Vista shall give the Resident 30 days written notice of any change in rental rate or changes for various services of Bella Vista." This "Residency Agreement" was signed by Tenant 1 on 1/28/09 and signed by (former) Executive Director L on 1/29/09. Tenant 1 was admitted to the facility on 1/31/09. Per Surveyor's review of facility records, on 1/16/11, POA E had written correspondence with (former) Administrator K which noted, "I am seeking explanation for the increased charges that differ from the original contract (Tenant 1) signed with Bella Vista in January of 2009. ... I have noticed inconsistencies with the original contract and unexplained charges that concern me. ... The billing statements I have received from CRL (Licensee) do not reflect the original contractual agreement. Additional fees have been assessed, without written notice, for both residence and medical services. ... during the period January 31, 2009 and December 31, 2009, (Tenant 1's) service fees had increased from $80.00 per month to $350.00 per month for level II services, and his basic residence package had gone from $200.00 per month to $550.00 per month. I did not at any time receive written notification. ... These unexplained charges were reflected in billing statements from September December, 2009 with further increases charged for both residence and medical services reflected in billing statements from January 2010 to present. ...I would like a full and detailed accounting of these charges, in writing, at your earliest convenience. ...". Surveyor reviewed additional e mail correspondence within the facility records in For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 6 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 154 Continued From page 6 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 154 which POA E noted the facility provided her with copies of the 2010 and 2011 charge/billing details including when increases occurred during that timeframe, however the facility did not provide 2009 detail of charges including rate increases, despite POA E specifically requesting the 2009 detailed information in written correspondences dated 1/16/11, 2/5/11, 2/11/11, and 2/24/11. On 9/18/12 and again on 12/13/12 Surveyor requested a detailed copy of 2009's billing charges for Tenant 1. On 12/13/12, Surveyor received "Customer Quick Report" which did not provide a breakdown of billing, so on 12/19/12 Surveyor conducted an interview with Accounting Staff M who informed Surveyor of each months charges in 2009 for Tenant 1. Accounting Staff M stated in February through August, 2009, the total charges for Tenant 1's occupancy and care was $2480.00 per month. This was $100.00 more per month than was agreed upon in the "Residency Agreement" at $2380.00 per month. Accounting Staff M believed the additional $100.00 was billing for utilities. Per Surveyor review of "Residency Agreement", the contract noted, "...utilities separate". Accounting Staff M further informed Surveyor that in September through December, 2009, Tenant 1's total charges increased to $3000.00 per month. Accounting Staff M said the database did not identify the reason for the increase in charges, but he thought it was likely a "level of care" increase. In September through December, there was a $620.00 increase from the agreed rate in the "Residency Agreement". Accounting Staff M stated that it would be the Executive Director's responsibility to provide Tenant 1/ POA E notification of the increase in charges. He stated he was not aware of any documentation to verify there was notification of rate increase within For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 7 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: A. BUILDING: ______________________ C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION U 154 Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 154 2009. Surveyor reviewed the facility records for 2010 billing details available ("Resident Detail Ledger"). Under 01/2010, the ledger noted the statement date as 12/28/09 and effective dates 01/01/2010 01/31/2010 and the following "charges": Private Room AL $480.00, County AL $2,170.00 (amount paid by health care insurance provider), Service Pack I AL (level of care fees) $350.00, Parking AL $50.00, Marketing Concessions ($50.00) (credit based on "Residency Agreement"). These amounts added equal $3,000.00. This is $620 more than the agreed rate of $2380 per the "Residency Agreement" on 1/31/09. On 9/8/12 and again on 12/13/12, Surveyor requested copies of any notification of rate increase sent to Tenant 1 and/or POA E between 1/31/09 and December, 2009. House Manager B and Administrator A verified that they did not have letters/notices of rate increases to demonstrate the 30 notification was provided to Tenant 1/POA E. Surveyor noted that a "Service Pack" (level of care) rate increased on the statement dated 12/13/10 from $365.00 to $600.00 and POA E documented in correspondence with the facility that she received notice of this particular increase. Surveyor reviewed the facility records for 2011 billing details ("Resident Detail Ledger"). Under 02/2011, the ledger noted on statement date 1/25/11, "Service Pack" again increased from $600.00 to $625.00. POA E noted she did not receive notification of this increase. On 9/18/12 and again on 12/13/12 Surveyor requested a copy of the notice of rate increase. House Manager B and Administrator A verified that they did not have a letter/notice of rate For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 8 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 154 Continued From page 8 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 154 increase to demonstrate that notification of the $25 increase was provided to Tenant 1/POA E. The facility failed to provide notification to Tenant 1/POA E when in February through August 2009 rates increased by $100.00 (a possibly utility charges), when in September, 2009 rates increased by $620.00, and again on 1/25/11 when rates increased by $25.00. U 171 89.26(4) ANNUAL REVIEW U 171 A tenant's capabilities, needs and preferences identified in the comprehensive assessment shall be reviewed at least annually to determine whether there have been changes that would nescessitate a change in the service or risk agreement. The review may be initiated by the facility, the county department designated under sub. (3)(c)2., or at the request of or on the behalf of the tenant. This Rule is not met as evidenced by: Surveyor: 28910 Based on record review and interview, the facility failed to review Tenant/Resident 1's Comprehensive Assessment at least annually to determine if there were changes which would necessitate a change in Tenant 1's Risk Agreement and/or Service Agreement ("Residency Agreement"). Two years after Tenant 1 was admitted, an episode occurred when Tenant 1 left the facility without signing out. Upon his return to the facility, Tenant 1 did not have a key card. Upon staff finding Tenant 1 outside the lobby doors, it was For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 9 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 171 Continued From page 9 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 171 reported by staff that Tenant 1 returned to the facility drunk, was highly agitated, and broke a window in an attempt to enter the locked building. Staff reported that Tenant 1 stated he thought he was going to "freeze to death waiting to be let in". Per written correspondence to the Administrator, POA E (Tenant 1's Power of Attorney) requested a review of the situation and necessary corrections implemented to prevent future occurrences. There was no Assessment completed annually (one year after admission) or after the incident (2 years after admission), despite the events and the POA's written request. Findings include: Per Surveyor 28910's review of the "Residency Agreement" between Tenant 1 and the facility, the following was handwritten in the contract, "$2300 plus $80 Med set-up monthly. $2380 per month Includes ... monthly nursing assessment, ..." Tenant 1 was admitted to the facility on 1/31/09. A pre-admission assessment was completed on 1/28/09 which included information that he had mild dementia, was a very pleasant person, liked to drink beer socially, maintained his drivers license and still drove his car. Further documentation noted that Tenant 1 kept his car in the garage at the facility. Surveyor observed via record review the second documented assessment for Tenant 1 was conducted and dated 4/15/11 (2 years and 3 months after Tenant 1's initial assessment). On 9/18/12, Surveyor 28910 conducted an interview with House Manager B, who stated after Tenant 1's admission, Tenant 1's mental capabilities began declining related to his For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 10 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 171 Continued From page 10 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 171 dementia. House Manager B stated that because of his mental decline, Tenant 1 was no longer allowed to independently administer his medication and staff began supervised medication administration. House Manager B stated that Tenant 1 began needing assistance with bathing and laundry due to urine odor and confusion. She stated his behaviors and agitation gradually increased and "he would go out drinking and come back (to the facility) drunk and upset." House Manager B stated, "You couldn't talk to him when he got upset." She further stated that when he went out of the facility he would frequently not have his "swipe card" (key card which allowed him access back into the locked facility after hours). House Manager B informed surveyor of a night when Tenant 1 threw something at the glass window to get in. Surveyor 28910 reviewed the "Resident Incident Report" referencing an event that occurred at 11:50 PM on 1/13/11. The report noted Tenant 1 "took a tripod stand from front entrance and slammed it into front door shattering glass door in an effort to get in door." Caregiver C provided a written statement that she observed Tenant 1 pounding on the door with the tripod and noticed that the glass was broken. Caregiver C noted that she opened the door for Tenant 1 and wrote, "(Tenant 1) had a lot to drink that night." Maintenance D provided a written statement which noted that he came upon Caregiver C and Tenant 1 in the front lobby and observed the broken door glass. Maintenance D described that Tenant 1 was screaming and demanding, subsequently calmed down, and then became upset again. Maintenance D wrote, "I asked (Tenant 1) where his key card was and he stated he didn't have one. ... (Tenant 1) appeared to be For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 11 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 171 Continued From page 11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 171 intoxicated and was assisted to his room by (Caregiver C). ... It should be noted that when I initially reported to work I did check the resident sign out/in log and (Tenant 1) was not listed as being out... This type of incident could be avoided in the future if: 1. (Tenant 1) would remember to keep his key card with him or 2. (Tenant 1) would sign out. ..." During an interview with House Manager B on 9/18/12, House Manager B acknowledged there should have been annual assessments conducted at least in January 2010 (approximately) and January 2011 (approximately), but that typically they assess more frequently than annually. House Manager B verified that she looked for other assessments and there were no 2010 or 2011 annual assessments. House Manager B also verified there was no assessment completed for Tenant 1 after the 1/13/12 incident noted above and no changes made to the Risk Agreement. During an interview with Administrator A on 12/14/12, she also verified that she looked for the 2010 and 2011 annual assessments and there were none. Cross Reference: U0115- Services U0211- Risk Agreement U 211 89.28(6) RISK AGREEMENT U 211 UPDATING. The risk agreement shall be updated when the tenant's condition or service needs change in a way that may affect risk, as indicated by a review and update of the comprehensive For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 12 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 211 Continued From page 12 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 211 assessment, by a change in the service agreement or at the request of the tenant or facility. This Rule is not met as evidenced by: Surveyor: 28910 Based on record review and interview, the facility failed to review/update Tenant/Resident 1's Risk Agreement, despite knowledge of Tenant 1's changing condition and increased risk. The facility was aware of his increased confusion, episodes of drinking, and potential for not having his key card with him which would allow access into the locked facility. There was no update to the Risk Agreement based on this knowledge. On 1/13/11, an episode occurred when Tenant 1 left the facility without signing out. Upon his return to the facility, Tenant 1 did not have a key card. Staff found Tenant 1 outside the lobby doors. It was reported by staff that Tenant 1 returned to the facility drunk, was highly agitated, and broke a window in an attempt to enter the locked building. Staff reported that Tenant 1 stated he thought he was going to "freeze to death waiting to be let in." Per written correspondence to the Administrator, POA E (Tenant 1's Power of Attorney) requested a review of the situation and necessary corrections implemented to prevent future occurrences. There was no update to the Risk Agreement, despite these events and the POA's written request for follow up. Findings include: Tenant 1 was admitted to the facility on 1/31/09. A pre-admission assessment was completed on 1/28/09 which included information that he had mild dementia, was a very pleasant person, liked For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 13 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 211 Continued From page 13 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 211 to drink beer "socially", maintained his drivers license and still drove his car. Further documentation noted that Tenant 1 kept his car in the garage at the facility. Upon admission, a "Risk Agreement" was completed on 1/31/09 which identified the following agreed upon courses of action based on Tenant 1's identified risks: "1. Resident (1) will self administer meds (medications) w/ (with) staff reminders. 2. Resident (1) will ask for assistance when needed. 3. Resident (1) will check in and out when leaving facility due to fire safety/fire drill needs and for resident's safety and security." Per Surveyor 28910 record review, there were no reviews/revisions/updates made to Tenant 1's admission "Risk Agreement" through his discharge date on 6/6/11. Surveyor observed via record review and verified via interview with House Manager B and Administrator C that there were no assessments completed after Tenant 1's admission until 4/15/11 (2 years 3 months after Tenant 1 was admitted). On 9/18/12, Surveyor 28910 conducted an interview with House Manager B, who stated after Tenant 1's admission, Tenant 1's mental capabilities began declining related to his dementia. House Manager B stated that because of his mental decline, Tenant 1 was no longer allowed to independently administer his medication and staff began supervised medication administration. Surveyor observed there was no update to the "Risk Agreement" to For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 14 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 211 Continued From page 14 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 211 note this change in Medication Administration for Tenant 1, despite the "Risk Agreement" had noted Self administer medications with staff reminders. House Manager B stated that Tenant 1 began needing assistance with bathing and laundry due to urine odor and confusion. She stated his behaviors and agitation gradually increased and "he would go out drinking and come back (to the facility) drunk and upset." House Manager B stated, "You couldn't talk to him when he got upset." She further stated that when he went out of the facility he would frequently not have his "swipe card" (key card which allowed him access back into the locked facility after hours). Surveyor observed there was no update to the "Risk Agreement" to incorporate an agreement for these noted risks. House Manager B informed Surveyor of a night when Tenant 1 threw something at the glass window to get into the facility. Surveyor 28910 reviewed the "Resident Incident Report" referencing an event that occurred at 11:50 PM on 11/13/11. The report noted that Tenant 1 "took a tripod stand from front entrance and slammed it into front door shattering glass door in an effort to get in door." Caregiver C provided a written statement that she observed Tenant 1 pounding on the door with the tripod and noticed that the glass was broken. Caregiver C wrote, "(Tenant 1) had a lot to drink that night." Maintenance D provided a written statement which noted that he came upon Caregiver C and Tenant 1 in the front lobby and observed the broken door glass. Maintenance D described that Tenant 1 was screaming and demanding, subsequently calmed down, and then became upset again. Maintenance D wrote, "I asked For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 15 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 211 Continued From page 15 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 211 (Tenant 1) where his key card was and he stated he didn't have one. ... (Tenant 1) appeared to be intoxicated and was assisted to his room by (Caregiver C). ... It should be noted that when I initially reported to work I did check the resident sign out/in log and (Tenant 1) was not listed as being out... This type of incident could be avoided in the future if: 1. (Tenant 1) would remember to keep his key card with him or 2. (Tenant 1) would sign out. ..." Surveyor observed there was no review/update to the "Risk Agreement" based on the recommendation of Security person D. During Tenant 1's record review, Surveyor observed e mail correspondence from POA E (Tenant 1's Power of Attorney) to the Administrator during this incident. In the e mail, POA E wrote, "We would appreciate a review of those policies and guidelines for security and response at Bella Vista and any necessary corrections to avoid any such incident from occurring to another loved one in your care at Bella Vista." Despite the request for facility review in order to prevent future occurrences, the facility did not update Tenant 1's "Risk Agreement." During an interview with Administrator A and RN F on 12/14/12, RN F verified there should be an update to the "Risk Agreement" in a situation as described above. Administrator A verified that she looked for documentation of "Risk Agreement" updates and none were completed. Cross Reference: 0115- Services For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 16 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 211 Continued From page 16 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 211 0171- Annual Review U 269 89.34(18) TENANT RIGHTS U 269 Rights of tenants. A tenant of a residential care apartment complex shall have all the rights listed in this section. These rights in no way limit or restrict any other rights of the individual under the U.S. Constitution, civil rights legislation or any other applicable statute, rule or regulation. Tenant rights are all of the following: (18) FREEDOM FROM ABUSE. To be free from physical, sexual or emotional abuse, neglect or financial exploitation or misappropriation of property by the facility, its staff or any service provider under contract with the facility. This Rule is not met as evidenced by: Surveyor: 10902 Based on interview and record review the facility neglected to meet the needs of safety, monitoring, assistance with transferring, toileting, nutrition and medication, including insulin administration for Tenant/Resident 2. On 9/6/11 Tenant 2 moved into Bella Vista RCAC (Residential Care Apartment Complex). Tenant 2 utilizes a motorized, battery operated wheel chair and is totally dependent upon others to transfer her in and out of the chair. On the day of admission, Tenant 2's wheel chair battery died and she was stranded just inside of her apartment door. Tenant 2 was not checked on or discovered until approximately 21 hours later, on 9/7/11. For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 17 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 269 Continued From page 17 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 269 The facility neglected to meet Tenant 2's safety needs of assisted transfers and monitoring. She was not given a call pendent which is utilized in this facility for residents to call for assistance. The facility neglected to meet her diabetic nutritional needs. The facility neglected to administer her insulin and other medications. She was not assisted with toileting or hygiene needs. She was left sitting in the same position unattended until an outside visitor found her. Tenant 2's right to be free from neglect was not protected by the facility. Findings include: On 10/12/11 the Department received a complaint that reported the following: Tenant 2 moved into the RCAC apartment at 3:00 pm on 9/6/11. Tenant 2 was diabetic and non-ambulatory and needed assistance with all cares, including toileting. On 9/7/11 at approximately 1:00 pm, Tenant 2 had a visitor who discovered that Tenant 2's electric wheel chair battery had died and the wheel chair was partially blocking her doorway. The direct care staff did not know that Tenant 2 had moved in. Tenant 2 did not have any assistance from anyone from 3:00 pm on 9/6/11 to 1:00 pm on 9/7/11. She is physically unable to get out of her wheel chair on her own. No one found her. She did not receive insulin, any food or cares. Tenant 2 was soaked through her clothes and her wheelchair seat was soaked. Per record review, the admission papers, including the Residency Agreement was signed by Tenant 2 on 8/31/11. The Residency Agreement read, "This Residency Agreement is made and entered into as of September 6, 2011 For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 18 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 269 Continued From page 18 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 269 and between Bella Vista...and (Tenant 2)... A facility memo dated 8/28/11 read, "Resident moving to RCAC asap (as soon as possible), has aprtm (apartment). Another memo dated 8/29/11 read, "Relocating resident asap to RCAC...Resident moving to RCAC asap, has apartment per (CMO-Care Management Organization) and Bella Conference...Relocating resident asap to RCAC waiting on maintenance to move furniture. Met with...and all on board." Per facility document entitled, "Yardi Incident Reporting Tool" an incident occurred on 9/7/11. Attached to the Yardi Incident form was a hand written note dated 9/7/11 and signed by Caregivers F and G. The note included the following: "...On 9/7/11 ...resident had apparently been sitting in power chair, which was dead since yesterday. She did not have a pendent (to call for help) and couldn't pull cord in bathroom or bedroom because chair was dead. She was saturated in urine. She was cleaned up and changed. No wash cloths, towels etc. in room....Nothing was communicated to any of the staff that (Tenant 2) was in the building. The med (medication) passers didn't even have medications for her. Later we found out there were meds at the front desk. (Tenant 2) is a diabetic and hadn't eaten anything since 9/6/11 in the afternoon before she arrived here..." A second hand written note (not dated), signed by RN H was also attached. This note included the following: "Resident arrived in building 9/6/11 in afternoon. Resident received no meds or insulin that night or til 1 pm on 9/7/11. She did not receive supper on 9/6/11 or Breakfast (or lunch) For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 19 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 269 Continued From page 19 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 269 on 9/7/11. Her blood sugar was 261 at 1:30 pm 9/7/11. She did not receive her am meds on 9/7/11 either...This was an insight (oversight?) by us and we have made a new procedure for new residents coming into facility to ensure it don't (doesn't) happen again." Per Surveyor 10902 request for additional information related to this incident, Senior Lifestyle Consultant J reported that she set up the time for Tenant 2's admission arrival and told RN H in person. Consultant J sent out an "Outlook invite to all Management-just to make them aware that she would be arriving on 9/6/11." Consultant J reported that Tenant 2's admission was discussed at the facility's morning stand-up management meetings for several days prior to her coming. Tenant 2's name, date of admission and room number was put "on the board." Consultant J explained that when Tenant 2 arrived on 9/6/11 she met with Tenant 2, went through the paperwork and gave her a tour of the facility. When Consultant J completed her admission work with Tenant 2, she "made a call to RN H's office. She (RN H) did answer and I let her know that Tenant 2 was here...The reason why I always let (RN H) know right away when the resident is in the building is because I know there are some important things she needs to do with her staff/putting together chart/etc....At that time I assumed (RN H) would have taken care of her part and had found out the next day on 9/7/11, that she had not." Per review of Tenant 2's "Resident Service Plan" also called Initial Assessment which was dated 9/18/12, the following was noted: -Transfers: 2 person assist -Toileting: Extensive Assist - Day and Night -Non-Ambulatory For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 20 of 21 PRINTED: 03/07/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED C 12/12/2012 STREET ADDRESS, CITY, STATE, ZIP CODE 631 HAZEL STREET OSHKOSH, WI 54901 BELLA VISTA (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0013150 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) U 269 Continued From page 20 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE U 269 On 9/18/12 Surveyor 10902 observed morning cares for Tenant 2. It was observed that staff used a mechanical lift to transfer Tenant 2 from her bed to her wheel chair. Staff completed all lower body cares for Tenant 2. On 9/18/12 per interview with Surveyor 10902, Tenant 2 verified that on 9/6/11 she had been left in her room in her electric wheelchair. She stated that just as she was about to go out the apartment door, the battery on her wheel chair died. She could not get to the call light or phone. Tenant 2 stated that she could not back up, or walk or go to the toilet. "I sat for a while and thought someone would come to check on me but nobody did. I had to go to the bathroom and I thought: I have 2 options; to go in my pants or hold it. I sat there all night long. I was under the impression they did every 2 hour rounds and that they would check on me. Nobody came. When I thought I heard something I would open the door, I could reach it and open it a couple of inches. Nobody was there. My visitor found me the next day. I did not want her (the visitor) to see me. I was so embarrassed because I had wet myself." The facility failed to protect Tenant 2 from neglect. For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 8LQD11 If continuation sheet 21 of 21