PRINTED: 04/18/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED R-C 02/27/2013 STREET ADDRESS, CITY, STATE, ZIP CODE 1628 N MAIN ST OSHKOSH, WI 54901 CENTENNIAL INN (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0009443 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {N 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 {N 000} Surveyor: 10902 On February 27, 2013 a verification visit and a complaint survey was conducted at Centennial Inn of Oshkosh. The 2 previous deficiencies were found to be corrected and 2 new citations were issued. N 244 83.21(2)(a) Training in client groups. N 244 Training shall be specific to the client group served and shall include the physical, social and mental health needs of the client group. Specific training topics shall include, as applicable: characteristics of the client group served, activities, safety risks, environmental considerations, disease processes, communication skills, nutritional needs, and vocational abilities. Client group specific training shall be completed within 90 days after starting employment. This Rule is not met as evidenced by: Surveyor: 10902 Based on interview and verified by record review the facility did not ensure that employees had specific client group training for those that they serve with emotional disturbances and/or mental illnesses. The facility is an 18 bed Class CNA (nonambulatory) CBRF (Community Based Residential Facility) licensed to serve the populations of advanced aged, physically disabled, irreversible dementia/alzheimer's and emotionally disturbed/mental illness. In October 2012, the facility requested to increase 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 ZI8Z12 If continuation sheet 1 of 5 PRINTED: 04/18/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED R-C 02/27/2013 STREET ADDRESS, CITY, STATE, ZIP CODE 1628 N MAIN ST OSHKOSH, WI 54901 CENTENNIAL INN (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0009443 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) N 244 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 N 244 the populations that they served to include residents who were emotionally disturbed and/or had mental illness. This client group was added to their license on 10/25/12. Though the facility had done a 30 minute power point presentation, it did not include the physical, social and mental health needs of the mentally ill or emotionally disturbed such as activities, safety risks, environmental considerations, disease processes, communication skills, nutritional needs, and vocational abilities. Resident 1 was admitted to the facility on 10/26/12 as a part of this client group. Resident 1 refused cares and medications. The refusals increased, the facility decided they were unable to meet her needs and she moved to another facility on or about 2/28/13. The facility did not complete the training required to assist Resident 1 and those with mental illness, specifically those with personality disorders. Findings include: On 2/22/13 the Department received a complaint that stated Resident 1 had received a 30 day notice to leave the facility and complained that the staff did not have the training needed on mental illnesses and related disorders. On 2/27/13 Surveyor 10902 reviewed Resident 1's record and noted that she had diagnoses that included anxiety, diabetes, schizophrenia, personality disorder and borderline personality. Surveyor reviewed Manager A's and Caregivers B and C's training files and noted that there was no documentation of training related to personality or borderline personality disorders. For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 ZI8Z12 If continuation sheet 2 of 5 PRINTED: 04/18/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED R-C 02/27/2013 STREET ADDRESS, CITY, STATE, ZIP CODE 1628 N MAIN ST OSHKOSH, WI 54901 CENTENNIAL INN (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0009443 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) N 244 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 N 244 On 2/27/13 per interview with Surveyor 10902 Caregiver C stated that she had not heard of borderline personalities. She stated that the facility has about 6 residents with schizophrenia. Caregiver B stated that training for behavioral health "is much needed." Per interview with Surveyor, Caregiver D stated that she was quite certain she had heard of borderline personality diagnoses but did not know what it meant. She verified she had not received training for working with those who have personality disorders. Per interview, Manager A verified that she nor the facility staff had training related to personality disorders and/or borderline personalities. During the facility exit, attended by Administrator E, Facility RN F and Manager A, all verified that they had not had the training in behavioral/mental illness needed to serve Resident 1. Manager A stated that she had requested behavioral health training from the county but that she had not gotten a response needed to set up the training. N 382 83.35(1)(b) Sources used for assessment N 382 information. Information gathering. The CBRF shall base the assessment on the current diagnostic, medical and social history obtained from the person ' s health care providers, case manager and other service providers. Other service providers may include a psychiatrist, psychologist, licensed therapist, counselor, occupational therapist, physical therapist, pharmacist or registered nurse. The administrator or designee shall hold a face-to-face interview with the person and the person ' s legal representative, if any, and family For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 ZI8Z12 If continuation sheet 3 of 5 PRINTED: 04/18/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED R-C 02/27/2013 STREET ADDRESS, CITY, STATE, ZIP CODE 1628 N MAIN ST OSHKOSH, WI 54901 CENTENNIAL INN (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0009443 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) N 382 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 N 382 members, as appropriate, to determine what the person views as his or her needs, abilities, interests, and expectations. This Rule is not met as evidenced by: Surveyor: 10902 Based on record review and verified by interview, the facility did not obtain pre-admission information from Resident 1's service providers and did not have sufficient information related to signs and symptoms of her diagnoses, medical, social, psychiatric history. The facility did not meet face-to-face with Resident 1 prior to admission and had not determined Resident 1's views related to her needs, abilities, interests and expectations. Resident 1 was admitted to the facility in October of 2012. Resident 1 refused to complete her own bathing and hygiene needs. She refused cares, medication and interventions by staff. These refusals increased and in February 2013, staff found that Resident 1 had an open wound on her foot. The facility served Resident 1 an involuntary 30 day discharge notice. The facility had not gathered full information prior to admission especially related to Resident 1's pattern of refusals and how to meet her care needs. Findings include: On 2/27/13 Surveyor 10902 reviewed Resident 1 recorded and noted the following: Resident 1 was admitted to the facility on 10/26/12 and had diagnoses that included: anxiety, diabetes hypothyroid, schizophrenia, personality disorder and borderline personality. Resident 1 was her own decision maker. For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 ZI8Z12 If continuation sheet 4 of 5 PRINTED: 04/18/2013 FORM APPROVED Wisconsin Department of Health Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED R-C 02/27/2013 STREET ADDRESS, CITY, STATE, ZIP CODE 1628 N MAIN ST OSHKOSH, WI 54901 CENTENNIAL INN (X4) ID PREFIX TAG A. BUILDING: ______________________ B. WING _____________________________ 0009443 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) N 382 Continued From page 4 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETE DATE N 382 The pre-admission data form was signed and dated 10/26/12. Surveyor reviewed the information and the following was noted: bathing=1 assist, dressing=set-up, oral health=needs encouragement, transfers=independent, ambulation=uses a walker, toileting=independent, eating=occasionally refuses to eat, communication=independent, fall risk=has had fall, will need hoyer to get up, diabetic=very brittle, do blood sugars, nutrition=diabetic, not always compliant, behaviors=verbally aggressive, resistive to cares at times, decision making=makes poor decisions. The pre-admission record did not contain further data or analysis related to anxiety, aggressive behaviors or refusals of cares. There was no resulting assessment such as: how Resident 1 presents with the current diagnoses, medical and social history, how previous health care providers, case manager and other service providers managed her care especially related to refusals. There was no documented discussion with Resident 1 prior to admission to determine what she viewed as her needs, abilities, interests, and expectations. On 2/27/13 at the daily exit attended by Administrator E, Manager A and RN F, RN F verified that the pre-admission assessment was incomplete and that a face-to-face interview had not been done. RN F stated that the assessment consisted of, "a quick, over the phone interview" with the nurse at the previous facility. For long term care providers, a plan of correction is required for class A, B, & C violations. STATE FORM 6899 ZI8Z12 If continuation sheet 5 of 5