Wheaton Franciscan Hc - Terrace At St Francis

that nurses were not administering scheduled pain medications to R29. UM-J stated that nurses were

physician was never consulted with that R29 was not being administered scheduled pain medication.

On 7/18/24, at 10:27 AM, Surveyor interviewed R29's primary physician (PP)-U who confirmed that PP-U was not made aware by facility nursing staff that R29 was not receiving R29's scheduled morphine and was not aware that R29 had developed a stage 1 pressure ulcer to the coccyx. PP-U confirmed PP-U should have been notified of these issues.

On 7/18/24, at 12:52 PM, Director of Nursing (DON)-B is aware that R29 was not receiving scheduled pain medications and does not know if R29's physician was notified. DON-B informed Surveyor that DON-B thinks the activated HCPOA was notified that R29 was going to the ER on [DATE] and will need to look for documentation in a soft file.

On 7/18/24, at 3:42 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that there is no documentation that the activated HCPOA was notified of R29 going out for the 6/3/24 x-ray to the ER and that the primary physician was not consulted with regarding the nurses not administering R29's scheduled morphine and of R29's new stage 1 pressure ulcer on R29's coccyx. At this time, no further information was provided by the facility in regards to notification not being completed for R29's injuries of unknown origin, the decision to transfer R29 to the ER for an x-ray, and the deterioration in R29's skin condition as evidenced by R29's stage 1 pressure ulcer on the coccyx.

On 7/29/24, at 12:33 PM, Surveyor reviewed additional information provided by the facility after the survey process was completed.

Surveyor continues to have concerns that the notification on 6/3/24 was not to R29's activated HCPOA.

Surveyor remains with concerns that R29's PP-U was not notified of R29's injuries of unknown injuries, that prescribed pain medications were not being administered, and that R29 developed a stage 1 pressure area.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

self report to the state agency dated 6/11/24 in regards to R29's femur fracture.

Surveyor asked

Surveyor asked NHA-A why R29's bruising to both the left and right eye, and the right great toe

stated that a written grievance was completed in regards to the injuries which NHA-A provided a copy to Surveyor. A signed grievance dated 5/23/24 by NHA-A documents that the bruising to R29's eyes were self inflicted by R29.

The intervention for R29's fractures was the buddy system.

Surveyor notes implementing the buddy system is not on R29's CNA worksheet or comprehensive care plan. NHA-A stated the right great toe fracture may be related to getting caught between the foot rest and side of Broda chair and the femur fracture is related to R29's diagnosis of osteoporosis. NHA-A stated that there was always an explanation and within 2 hours we identified it was all self inflicted.

Surveyor notes that the grievance was initiated on 5/16/24, however, bruising to the left eye was discovered on 5/2/24.

Surveyor shared with NHA-A that R29's injuries that were not reported meet the definition of Injuries of unknown source as R29 could not explain, there was no witness, and based on the location and number of injuries sustained by R29.

On 7/29/24, at 12:33 PM, Surveyor reviewed additional information provided by the facility after the survey process was completed.

Surveyor continues to have concerns that R29's injuries of unknown origin at the time of discovery was not submitted to the State Survey agency.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

hoyered at that time. HRN-S noticed blood and found a laceration between R29's right great toe and

either happened when R29 was up for meals and may have accidentally hit it and the facility stated

side and didn't understand. HRN-S has never observed R29 to be restless or thrashing around when up in the Broda chair. R29 ends up with confirmation of a right great toes fracture on 5/22/24. HRN-S stated there was no swelling present to R29's right knee between 5/23-5/28/24. On 6/3/24, R29 is found to have a right distal femur fracture.

On 7/16/24, at 3:49 PM, Nursing Home Administrator (NHA)-A informed Surveyor that R29 has had no falls in the past 6 months.

On 7/18/24 at 3:42 PM, Surveyor shared with NHA-A the concern that R29 had an injury of unknown origin resulting in bruising to left and right eye, and the fracture of the right great toe and the right femur fracture. NHA-A stated the fractures are a result of R29's osteoporosis.

Surveyor shared the concern that R29 appeared with bruising to the left and right eye on 2 separate occasions and the fracture to the right great toe, that there is no documentation that the facility submitted the injuries of unknown injury to the state survey agency. At this time, NHA-A had no further information.

On 7/22/24, at 1:23 PM, Surveyor interviewed NHA-A in regards to R29's injuries.

Surveyor requested any additional information that NHA-A had on R29's injuries Surveyor notes the facility submitted a self report to the state agency dated 6/11/24 in regards to R29's femur fracture.

Surveyor asked NHA-A about the documented statement in the self report summary stating, Furthermore, on 5/16, R29 had a Broda chair transfer incident in which R29's right foot got caught up in the foot rest.

Surveyor asked NHA-A why R29's bruising to both the left and right eye, and the right great toe fracture and laceration requiring 2 stitches was not reported to the state survey agency. NHA-A stated that a written grievance was completed in regards to the injuries which NHA-A provided a copy to Surveyor. A signed grievance dated 5/23/24 by NHA-A documents that the bruising to R29's eyes were self inflicted by R29.

The intervention for R29's fractures was the buddy system.

Surveyor notes implementing the buddy system is not on R29's CNA worksheet or comprehensive care plan. NHA-A stated the right great toe fracture may be related to getting caught between the foot rest and side of Broda chair and the femur fracture is related to R29's diagnosis of osteoporosis. NHA-A stated that there was always an explanation and within 2 hours we identified it was all self inflicted. An undated signed statement from Social Worker (SW)-O documents that every Resident was interviewed on the second floor, however, Surveyor was not provided upon request those Resident interviews. NHA-A provided a copy of staff statements and none of the staff statements are signed and dated.

The staff statements are specific to whether or not R29 had a fall.

Surveyor notes that the grievance was initiated on 5/16/24, however, bruising to the left eye was discovered on 5/2/24.

Surveyor shared with NHA-A that R29's injuries that were not reported meet the definition of Injuries of unknown source as R29 could not explain, there was no witness, and the location and number of injuries sustained by R29.

Surveyor shared the concern that a thorough investigation was not completed in regards to R29's injuries.

Surveyor also notes that HRN-S provided written statements for R29's observed injuries and the facility did not have documentation of these statements.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

facility and came back to current facility about a month ago. RN-G stated there are quite a few

access to the Residents EMR.

On 7/18/24, at 3:54 PM, Nursing Home Administrator (NHA)-A informed Surveyors that the Resident MDS(s) should have been put on paper and believes there were some challenges going through the CMS website.

Surveyor shared the concern that R18 and R21's Annual MDS(s) were not completed and submitted by the designated time. NHA-A provided no additional information at this time.

Surveyor requested the facility's Emergency Preparedness plan for when EMR access is not available.

On 7/22/24, at 7:56 AM, Surveyor received the undated EMR Disaster and Downtime Process which documents: .Unanticipated EMR Downtime -In advance routinely make sure that downtime forms are printed, accessible, and current. -During downtime, locate downtime devices and print face sheets, medication and treatment administration records, locate downtime forms, and document on paper. -After, paper documentation becomes part of the legal medical record and recommend scanning into EMR as soon as possible.

Surveyor notes it is not documented what to do to complete and submit Resident MDS(s) in the EMR Disaster and Downtime Process instructions.

On 7/25/24 the facility submitted additional documentation which was reviewed and did not change the concerns being cited

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

-During downtime, locate downtime devices and print face sheets, medication and treatment

-After, paper documentation becomes part of the legal medical record and recommend scanning into EMR as soon as possible.

Surveyor notes it is not documented what to do to complete and submit Resident MDS(s) in the EMR Disaster and Downtime Process instructions.

On 7/22/24, at 9:46 AM, Surveyor reviewed R25 and R29's EMR and notes that R25's Quarterly MDS was completed and submitted on 7/18/22 and R29's Quarterly MDS was completed and submitted on 7/17/24, during the recertification survey.

On 7/25/24 the facility submitted additional documentation which was reviewed and did not change the concerns being cited. 4.) On 7/15/24 Surveyor reviewed R50's medical record and Minimum Data Set (MDS) assessments and noted: R50 had an admission MDS with an ARD of 12/5/2023. R50 had a Quarterly MDS with an ARD of 02/09/2024, which was completed and submitted on 03/04/2024. R50 had a Quarterly MDS with an ARD of 05/08/2024, with a submission date of 07/17/2024.

Surveyor noted the most recent quarterly MDS was not completed until the recertification survey had started.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

and Federal requirements.

Policy Interpretation and Implementation C. If the Resident sustains a witnessed head trauma or an unwitnessed fall, the Resident should be observed for neurological abnormalities.

Neurological checks are initiated and completed for 72 hours.

If abnormal symptoms occur, the health care provider should be notified.

On 7/16/24, at 1:49 PM, Surveyor reviewed R25's unwitnessed fall investigation. R25 was trying to reach for a Gatorade, forgot R25 had 1 leg, and fell in the process. R25 was helped off the floor and placed back in bed.

Surveyor is unable to locate any neurological checks (neuro checks) completed for R25's 6/30/24 unwitnessed fall in R25's medical record.

On 7/17/24, at 7:26 AM, Surveyor interviewed Unit Manager (UM)-J. UM-J confirmed that if a resident has an unwitnessed fall, that neuro checks should be completed.

Surveyor shared that Surveyor is unable to locate the neuro checks for R25's unwitnessed fall on 6/30/24. UM-J stated UM-J will look for R25's neuro checks.

On 7/17/24, at 3:51 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that there are no documented neuro checks for R25's 6/30/24 unwitnessed fall. No further information was provided at this time by the facility.

The facility has been unable to provide completed neuro checks for R25's 6/30/24 unwitnessed fall.

On 7/22/24, at 9:07 AM, Surveyor interviewed Director of Nursing (DON)-B in regards to neuro checks.

DON-B stated that neuro checks are documented on paper. DON-B stated the initial neuro check is completed right after the fall. DON-B then stated that neuro checks should be every 15 minutes times 4, every 30 minutes times 4, every hour times 4, and once a shift (3) for 3 days. DON-B confirmed that all neuro checks should be completed with all unwitnessed falls.

Surveyor shared the concern with DON-B that neuro checks have not been located for R25's 6/30/24 unwitnessed fall. DON-B stated DON-B will need to look for R25's neuro checks.

On 7/22/24, at 2:47 PM, Surveyor received from NHA-A neuro checks for R25.

Surveyor notes the initial neurological check is completed.

There are only 2 15-minute neuro checks completed, not 4.

There are only 2 30-minute neuro checks completed, not 4.

There are only 2 every hour assessments completed, not 4.

Only 1 shift is completed with a date of 6/30/24. 2 shifts for 7/2/24 completed with 1 not signed and 2 shifts dated 7/3/24 that are not signed.

Surveyor notes there are no documented neuro checks completed for 7/1/24.

Surveyor shared with NHA-A that R25 not having neuro checks completed for R25's 6/30/24 fall remains a concern. NHA-A had no further information at this time.

On 7/29/24, at 12:33 PM, Surveyor reviewed additional information provided by the facility after the survey process was completed.

Surveyor noted the submitted forms reviewed do not identify a resident name or room number on the forms.

Surveyor continues to have concerns that R25's neuro checks are not completed per procedure of the facility that was provided by the DON-B on 7/22/24.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

be notified along with the primary and confirmed that daily and as needed skins checks should be

R29 needed to be seen by WMD-W but does not recall the exact date. DON-B does not know why WMD-W did not see R20 on 7/15/24. DON-B confirmed the air mattress setting is determined by weight.

On 7/18/24, at 10:27 AM, Surveyor interviewed R29's primary physician (PP)-U via phone who stated PP-U was not notified by the facility that R29 had any pressure areas.

On 7/18/24, at 10:37 AM, Surveyor interviewed HRN-S again. HRN-S informed Surveyor that medi honey is not ordered as the treatment to R29's open area. HRN-S confirmed that DON-B was told last week to place R20 on WMD-W list to be seen but was informed that R29 did not get seen because state was in the facility. HRN-S confirmed that on 6/20/24 both RN-L and DON-B were informed of R29's stage 1 pressure area on the left buttock and coccyx.

On 7/18/24, at 11:19 AM, Surveyor spoke with WMD-W via phone. WMD-W confirmed that WMD-W was first notified on 7/17/24 in the morning that R29 needed to be evaluated by WMD-W.

Surveyor asked WMD-D how important are air mattress settings to be correct. WMD-D stated It is very important to be correct. Do not want to be incorrect and have a Resident 'bottom out'. WMD-D confirmed the setting is based on a Resident's weight.

On 7/18/24, at 4:06 PM, Surveyor again shared the concern with NHA-A that R29's heel, left buttock, and coccyx has not been assessed with measurements by the facility.

Surveyor shared that hospice had requested on 7/11/24 for R29 to be seen by the WMD-W and that was not initiated by the facility and the treatment order for the coccyx was not entered until 7/17/24 after Surveyor expressed concern.

Surveyor stated that R29's air mattress has not been set at the correct setting during the survey process and R29's primary[TRUNCATED]

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

external fixator, was non weight bearing for a while, she was weak, and very motivated to work with

replied Hoyer because of the external fixator.

Surveyor asked if R13 was a Hoyer transfer during the

taken out.

Surveyor asked PTA-EE when R13's transfer status changed. PTA-EE informed Surveyor he didn't know.

Surveyor asked PTA-EE if he could find out when R13 was no longer a Hoyer transfer and could bear weight.

On 7/18/24, at 10:40 a.m., Surveyor asked DON (Director of Nursing)-B if she knew R13. DON-B informed Surveyor the day she came back, R13 went to the hospital and doesn't have any information regarding R13.

On 7/18/24, at 11:00 a.m., Surveyor spoke with COTA/DOR (Certified Occupational Therapy Assistant/Director of Rehab)-N. COTA/DOR-N informed Surveyor R13 went back to the hospital on 4/17/24 to get the fixator removed and when she came back she was weight bearing as tolerated with a cam boot. COTA/DOR-N informed Surveyor she doesn't have a copy of the order but they all go into the system.

Surveyor asked COTA/DOR-N if R13 was a Hoyer transfer on 3/29/24. COTA/DOR-N replied yes because she was non weight bearing with left foot and per the therapist at the end of her stay she was walking about 60 feet.

On 7/18/24, at 12:22 p.m., Surveyor asked NHA (Nursing Home Administrator)-A who Surveyor could speak with regarding R13's fall on 3/29/24 as at the time of the fall R13 was non weight bearing with a Hoyer lift and the CNA transferred R13 by herself. NHA-A informed Surveyor the staff here now weren't here. NHA-A informed Surveyor he will get the number of 3 staff who were here and see if they will speak with Surveyor.

On 7/18/24, at 4:06 p.m., during the end of the day meeting Surveyor informed NHA-A Surveyor has a concern the facility's investigation for R13's fall on 3/29/24 does not address the CNA transferring R13 by herself when R13 was a Hoyer lift.

Surveyor informed NHA-A R13 was a Hoyer lift transfer until 4/17/24 when she went to the hospital to have the external fixator removed.

On 7/22/24, at approximately 8:00 a.m., NHA-A provided Surveyor with LPN-GG's name and phone number.

Surveyor was not provided with any other staff to contact.

On 7/22/24, at 9:15 a.m., Surveyor spoke with LPN-GG on the telephone.

Surveyor informed LPN-GG Surveyor wanted to speak with her about R13 who had a fall on 3/29/24.

Surveyor asked LPN-GG if she remembers R13. LPN-GG informed Surveyor she doesn't remember R13 and then informed Surveyor she remembers one time on the 3rd floor there was a resident who was lowered to the floor.

LPN-GG informed Surveyor she was by herself and called the manager. LPN-GG informed Surveyor she wasn't sure if she did the SBAR or the manager did.

Surveyor read LPN-GG her nurses note dated 3/29/24 and asked if she was involved in the investigation. LPN-GG replied no. LPN-GG informed Surveyor the manager was going to take care of everything.

Surveyor informed LPN-GG Surveyor was looking into why the CNA transferred R13 by herself when R13 was a Hoyer transfer. LPN-GG inf[TRUNCATED]

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

catheter care, and appropriate care to prevent urinary tract infections.

observation, interview, and record review the facility did not ensure 1 (R315) of 2 residents reviewed

Surveyor had several observations during survey of R315's catheter bag not covered in a privacy bag and was visible from the hallway. R315's care plan was not revised to indicate if R315 did not mind if R315's catheter bag was visible to others.

Findings include: R315 was admitted to the facility on [DATE] and has diagnoses that include encounter for surgical after care (placement of urostomy) following surgery on the digestive system, bowel obstruction, ESBL (extended spectrum beta-lactamase) infection, and weakness.

R315's baseline care plan initiated on 7/12/2024 indicated R315 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15. R315 used a wheeled walker and limited assist of 1 staff member for transferring, mobility, and toileting. R315 was admitted with a urostomy and right arm PICC (peripherally inserted central catheter) line to have antibiotics administered through.

On 7/15/2024, at 10:57 AM, Surveyor observed R315 lying in bed watching TV. R315 stated R315 was tired and wanted to rest.

Surveyor observed R315 had a catheter bag located on the right side of R315's bed with a small amount of hematuria (bloody urine).

Surveyor asked R315 regarding the hematuria. R315 stated that R315 just had the urostomy placed and was to be expected and would clear up. R315 stated R315 was on antibiotics for it because R315 developed a major infection.

Surveyor noted that R315's catheter bag was visible from the hallway and not in a privacy bag.

On 7/16/2024, at 7:50 AM, Surveyor observed R315 sleeping in bed, R315's catheter bag was on the right side of the bed, visible from the hallway, and not in a privacy bag.

Surveyor noted a small amount of hematuria in catheter bag.

On 7/17/2024, at 7:38 AM, Surveyor observed R315 lying in bed watching TV.

Surveyor noted R315's catheter bag on the rights side of the bed, visible from the hallway, and not in a privacy bag.

Surveyor noted a small amount of light yellow urine in bag with streaks of red through it. R315 stated R315 noticed urine was looking better.

On 7/18/2024, at 9:19 AM, Surveyor shared observations with unit manager (UM)-J and director of nursing (DON)-B regarding R315's catheter bag not in a privacy bag and visible from the hallway.

UM-J stated R315's family member wanted the catheter bag uncovered so they were able to see it.

Surveyor stated that R315 was R315's own person and if it was ok with R315 the care plan was not revised to indicate that R315 did not want the catheter bag covered. UM-J and DON-B expressed understanding with Surveyors concerns.

525552 07/22/2024

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

R11 denied feeling dry.

tubing and humidification not being labeled and R11's humidification was dry/ empty all day on

watching TV. R11's tubing was not labeled and there was now a new humidification jar on the concentrator but was not labeled as to when it was put on. UM-J shared understanding of concerns and agreed that the oxygen tubing and humidification needs to be labeled and checked on frequently especially if R11's oxygen gets turned up. UM-J stated that typically NOC/3rd shift is responsible for changing out the tubing and humidification for oxygen concentrators.

On 7/18/2024, at 4:10 PM, Surveyor shared concerns with nursing home administrator (NHA)-A regarding R11's oxygen tubing and humidification not being labeled during survey and R11's humidification was dry/empty all day on 7/17/2024. NHA-A shared understanding of Surveyors concerns.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

never called hospice to communicate they were not giving R29's prescribed pain medications. HS-V

HRN-S stated HRN-S has never seen the lidocaine patch on R29 and when HRN-S asked RN-L about it, RN-L responded where am I supposed to put it.

On 7/18/24, at 12:52 PM, Director of Nursing (DON)-B is aware that R29 was not receiving scheduled pain medications and does not know if R29's physician was notified. DON-B understands the concern that no new pain assessment was completed by the facility when R29 sustained the right great toe fracture and and the right femur fracture and agreed the expectation would be to have new ones completed.

On 7/18/24, at 3:42 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern that there is no documentation that the facility was monitoring R29's pain level every shift in May and June.

Surveyor shared there are multiple nursing progress notes that R29's scheduled morphine was not administered to R29, and hospice had to frequently ask for R29's pain medication to be administered and educate facility nurses on the importance to administer R29's pain medication in order to provide comfort and quality of life to R29. No further information was provided by the facility at this time in regards to R29's pain management.

On 7/29/24, at 12:33 PM, Surveyor reviewed additional information provided by the facility after the survey process was completed.

Surveyor reviewed the pain evaluation provided, however, Surveyor still has concerns.

The pain evaluation is not dated.

Surveyor continues to have concerns that R29's scheduled pain medication was not administered on several occasions and R29's pain level was not monitored every shift as physician orders documented for the month of May and June.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

Consult follow-up concerns. NHA-A did not provide any additional information.

mellitus, dementia, Alzheimer's, anxiety disorder, major depressive disorder, heart failure, pulmonary

of gait and balance, and chronic respiratory failure with hypoxia.

On 7/16/2024, at 3:07 PM, Surveyor requested from nursing home administrator (NHA)-A to see R11's pharmacy medication reviews from January 2024 - current.

On 7/17/2024, Surveyor again requested to see pharmacy medication reviews for R11 from NHA-A for January 2024- current.

On 7/18/2024, Surveyor reviewed R11's pharmacy medication reviews and noted there was not a pharmacy review for January 2024 and February, March, April, May, June, and July pharmacy reviews were not signed or dated by a physician indicating the pharmacy reviews were looked at or acted upon.

On 7/18/2024, at 10:14 AM, a Surveyor interviewed director of nursing (DON)-B who stated DON-B started looking at the pharmacy reviews a few weeks ago. DON-B stated there is a binder when reports are received from pharmacy and physicians are to review them to, they can indicate if they agree or disagree with the recommendation. DON-B stated DON-B was sent some stuff from the pharmacy and is trying to get caught up.

On 7/18/2024, at 1:15 PM, Surveyor was handed pharmacy review sheets for May, June, and July 2024 that was signed by the physician but there is no date documented when the physician reviewed the recommendations.

Surveyor still has not received January 2024 pharmacy med review and indication that the physician reviewed the pharmacy reviews for February, March, or April 2024.

On 7/18/2024, at 4:10 PM, Surveyor shared concern with NHA-A that R11's pharmacy medication reviews for January, February, March, and April 2024 were not reviewed by a physician to indicate if the physician agrees or disagrees with the pharmacy recommendation. No further information was provided at this time.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

Surveyor informed NHA-A there is no stop date or documented rationale beyond 14 days for R5's PRN

On 7/18/24, at 10:20 a.m., Surveyor informed DON-B of the concern of R5's PRN Ativan 0.5 mg does

this medication needs to be extended by 14 days.

On 7/22/24, at 7:45 a.m., NHA-A provided Surveyor with physician orders for 7/18/24 which documents an order date of 5/6/24 Ativan Tab 0.5 mg - .5 mg by mouth every 8 hours as needed Administer .5 mg every eight hours by mouth for anxiety. [Physician-BB's name]; with a stop date of 11/02/24.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

On 2/20/24, Dietitian (DIET)-Q documented in the Nutrition Risk Assessment that R25 has chewing

receiving tube feedings.

Nursing reported to DIET-Q that R25 was only consuming pudding. DIET-Q documents that speech will be working with R25 on diet texture.

On 7/15/24, at 10:00 AM, R25 was interviewed by Surveyor and R25 stated R25 has not been offered dental services and would like to see a dentist to get R25's teeth removed so R25 can get dentures to eat better.

Surveyor observed only 4-5 teeth in R25's mouth and the teeth are black in color. R25 stated most of R25's upper teeth are gone and R25 has difficulty in chewing. R25 stated no one has asked R25 if R25 wanted to be seen by the dentist.

On 7/17/24, at 10:25 AM, Surveyor interviewed Social Worker (SW)-O. SW-O stated that a Resident's consent for dental services is received upon admission.

Medical Records (MR)-R is the keeper of the list. MR-R puts a Resident on the list to be receive services and reaches out to the specialists. SW-O states that between nursing and SW-O consents are obtained.

Surveyor communicated that R25 has not received dental services since admission and has not been approached about seeing the dentist.

SW-O indicated that R25 may have refused services and will look for documentation.

On 7/17/24, at 10:43 AM, MR-R informed Surveyor that MR-R gets an email of who wants to be seen, lets the specialist know, and does not know if Residents are asked on admission. MR-R has no record of R25 being on the dental list.

On 7/17/24, at 10:48 AM, Surveyor interviewed R25 again and asked if R25 wanted to be seen by the dentist. R25 responded, I have to. I want to be seen by a dentist.

On 7/17/24, at 10:56 AM, admission Coordinator (AC)-P informed Surveyor that AC-P is responsible for getting admission paperwork signed, but any individual consents are obtained by SW-O. AC-P obtains a signature authorizing physicians such as a dentist to provide dental care.

On 7/17/24, at 3:51 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R25 was offered to receive dental services since admission.

Per NHA-A, we offer the services within 6 months. NHA-A stated there was different leadership prior to May.

Surveyor shared there is no documentation that the need for dental services has been addressed for R25's quality of life.

On 7/18/24, at 3:42 PM, no further documentation was provided that R25 had been offered dental services at admission to address R25's dental concerns.

Documentation provided by facility indicates it was first discussed with R25 on 7/17/24, after it was brought to the attention of the facility by Surveyor.

On 7/29/24, at 12:33 PM, Surveyor reviewed additional information provided by the facility after the survey process was completed.

Surveyor notes the audit and documentation provided occurred after Surveyor brought it to the attention that R25 was not provided the option of dental services.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

metal utensils, a styrofoam cup with a straw, a hamburger bun with breaded meat and cooked carrots.

family member will fill out meal request slips for the week.

Surveyor inquired what the process is if a

form to indicate resident needs and they give the form to kitchen dietary aides. DON-B informed Surveyor that she did not see the dietary assessment note about special utensils for R40 until surveyor pointed it out.

On 07/17/2024, at 11:16 AM, Surveyor interviewed Dietician-Q who informed Surveyor that recommendations for special utensils and cups would come from anyone and once a recommendation was made, the expectation is to have those implemented.

On 07/17/2024, at 11:40 AM, Surveyor interviewed Speech Therapist (ST)-UU who informed Surveyor that she no longer works at the Facility. ST-UU states that in June ST-UU evaluated R40 and R40 was on a mechanical soft diet and was upgraded to a regular diet a couple weeks after readmission.

On 07/18/2024, at 07:57 AM, Surveyor observed R40 up in R40's wheelchair. R40's breakfast tray was on bedside table, LPN-VV assisting R40 with breakfast.

Surveyor observed special utensils and cup now provided to R40.

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Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

of dishes on 7/15/24 and 7/16/24.

Surveyor notes that 2nd floor dish machine is now at 135 and 3rd

140F, but the facility policy is 120F. FSS-F will confirm with the dish machine representative if it

rinse.

525552 07/22/2024

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

washed her hands and left R5's room.

incontinence product along R5's right side and then positioned R5 from side to side to straighten out

her closet, removed the shirt R5 was wearing, applied deodorant and placed the new shirt on. CNA-DD combed R5's hair, placed a clip in her hair, lowered the head of the bed and asked Surveyor if Surveyor could help boost R5.

After Surveyor explained Surveyor could not assist, CNA-DD used the pad and positioned R5 up in bed. CNA-DD placed pillows under R5's left & right side, under R5's lower legs and raised the head of the bed. CNA-DD covered R5 with a sheet, placed a towel, call pad, remote & purse on R5's bed. CNA-DD removed her gloves & gown and then cleansed her hands.

Surveyor noted this is the first time CNA-DD performed hand hygiene during this observation.

On 7/18/24, at 9:34 a.m., Surveyor asked RN/UM (Registered Nurse/Unit Manager)-AA when CNAs are doing incontinence cares when should hand hygiene be performed. RN/UM-AA informed Surveyor when switching from dirty to clean explaining when doing bowel care after cleaning should remove their gloves and perform hand hygiene.

Surveyor informed RN/UM-AA of the observation with R5 & CNA-DD.

Surveyor asked RN/UM-AA when should the nurse perform hand hygiene during a treatment.

RN/UM-AA informed Surveyor when the nurse enters the room, after taking the dressing off, after cleansing the wound and at the end of the treatment.

Surveyor informed RN/UM-AA of the hand[TRUNCATED]

525552 07/22/2024

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215

F-F756.

Physician-BB's progress note dated 6/22/24 does not address R5's PRN Ativan.

On 7/17/24, at 9:37 a.m., Surveyor met with RN/UM (Registered Nurse/Unit Manager)-AA to discuss R5.

Surveyor informed RN/UM-AA Surveyor wasn't able to locate a stop date or rationale to continue R5's PRN Ativan. RN/UM-AA informed Surveyor R5 is hospice and those order come from hospice. RN/UM-AA informed Surveyor she may have to touch base with DON (Director of Nursing)-B.

Surveyor asked RN/UM-AA if she could get back to Surveyor.

525552

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525552 B.

Wing 07/22/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wheaton Franciscan Hc - Terrace at St Francis 3200 S 20th St Milwaukee, WI 53215