Wisconsin Top Ten Federal Health Citations 1/1 11/27/2017

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Wisconsin Top Ten Federal Health State 1 1 F323 2 2 F441 3 3 F314 4 F22 F309 4 F371 7 9 F329 8 7 F42 9 8 F31 F17 Description Regulation control the spread infection Report and investigate allegations highest practicable level wellbeing unnecessary drugs accurate acquiring and dispensing Consult promptly with physician following significant condition change Cites 1 37 18 148 0 112 3 1 27 4 2 9 1 91 1 8 3 71 13

Southern Regional Office (SRO) Top Ten Federal Health SRO 1 1 F323 2 3 F314 3 2 F22 4 4 F441 Description Regulation Report and investigate allegations control the spread infection Cites 49 38 20 3 0 34 2 9 F17 Consult promptly with physician following significant condition change 28 7 8 F329 unnecessary drugs 28 0 7 F309 8 F371 9 7 F42 F31 highest practicable level wellbeing accurate acquiring and dispensing 24 23 0 19 0 2 F334 Offer influenza and pneumococcal immunizations 0

Southeastern Regional Office (SERO) Top Ten Federal Health SERO 1 1 F323 2 2 F314 3 3 F309 Description Regulation environment/supervision & assistive devices to prevent highest practicable level wellbeing Cites 8 17 47 1 4 4 9 F329 unnecessary drugs 40 0 4 F22 Reporting and investigating allegations abuse, mistreatment, neglect and 3 2 7 F371 Store, prepare, and serve food under sanitary conditions 31 1 F441 8 8 F42 spread infection accurate acquiring and dispensing 31 2 30 0 9 F17 Consult promptly with physician following significant condition change 29 F279 Develop comprehensive plan care 2 0

Northeastern Regional Office (NERO) Top Ten Federal Health NERO 1 1 F441 2 F314 3 2 F31 4 3 F323 Description Regulation control the spread infection Cites 0 1 3 3 0 31 2 4 F371 28 0 4 F42 7 7 F22 accurate acquiring and dispensing Report and investigate allegations 28 0 2 1 8 8 F22 Policies to prohibit abuse 21 1 9 F309 highest practicable level wellbeing 17 4 9 F332 Free medication error rates % or higher 1 0

Northern Regional Office (NRO) Top Ten Federal Health NRO 1 2 F441 Description Regulation control the spread infection Cites 17 0 2 F314 1 2 7 F323 4 1 F371 1 4 14 1 F332 Medication error rate is not greater than % 12 0 8 F309 3 F31 8 F22 9 F278 highest practicable level wellbeing Report and investigate allegations Assessment must accurately reflect resident status 0 9 0 8 0 9 F329 unnecessary drugs 7 0

Western Regional Office (WRO) Top Ten Federal Health 1 WRO 1 F441 2 4 F309 3 1 F323 4 F314 Description Regulation control the spread infection highest practicable level wellbeing Cites 2 0 14 2 13 4 12 2 F282 Services meet pressional standards and are provided in accordance with care plan 9 0 8 F329 unnecessary drugs 9 0 7 F280 Periodically review and revise the plan care 8 0 7 3 F371 8 0 7 F42 accurate acquiring and dispensing 8 1 7 F22 Report and investigate allegations 7 0 F318 Services to increase range motion or prevent avoidable decline in range motion 7 0

Nation F323 - supervision to prevent (14) control (09) TOP TEN FEDERAL HEALTH CITATIONS NATION, STATE, REGIONAL OFFICE State F323 - supervision to prevent (1) control (18) Southern (Madison) F323 - supervision to prevent (49) pressure ulcers (38) Southeastern (Milwaukee) F323 - supervision to prevent (8) pressure ulcers (47) Northeastern (Green Bay) control (0) pressure ulcers (3) Northern (Rhinelander) control (17) pressure ulcers (1) Western (Eau Claire) control (2) promotes highest level wellbeing (14) prepare, and serve food under sanitary conditions (3) level well-being (132) F431 - labeling drugs and biological (32) F279 - develop comprehensive care plan (348) F329 - drug regimen is free unnecessary drugs (3071) F14 - documentation (3047) F22 - investigate allegations abuse (292) F22 DEVELOP AND IMPLEMENT POLICIES AND PROCEDURES PROHIBITING ABUSE (218) pressure ulcers (148) F22 - investigate allegations abuse (112) level well-being (1) prepare, and serve food under sanitary conditions (4) F329 - drug regimen is free unnecessary drugs (9) F42 - medication accurate receipt and administration (91) F31 - services to restore normal bladder function and prevent infection (8) F17 PROMPT MD CONSULTATION (71) F22 - investigate allegations abuse (3) control (34) F17 Prompt MD consultation (28) F329 - drug regimen is free unnecessary drugs (28) level wellbeing (24) prepare, and serve food under sanitary conditions (23) F42 - medication accurate receipt and administration (19) F31 - SERVICES TO RESTORE NORMAL BLADDER FUNCTION AND PREVENT INFECTION () level wellbeing (4) F329 - drug regimen is free unnecessary drugs (40) F22 - investigate allegations abuse (3) prepare, and serve food under sanitary conditions (31) control (31) F42 - medication accurate receipt and administration (30) F17 PROMPT MD CONSULTATION (29) F279 DEVELOP COMPREHENSIVE PLAN OF CARE (2) F31 - services to restore normal bladder function and prevent infection (3) F323 - supervision to prevent (31) prepare, and serve food under sanitary conditions (28) F42 - medication accurate receipt and administration (28) F22 - investigate allegations abuse (2) F22 develop and implement policies and procedures prohibiting abuse (21) F309 - CARE PROMOTES HIGHEST LEVEL OF WELL-BEING (17) F332 medication error rate not greater than % (1) F323 - supervision to prevent (1) prepare, and serve food under sanitary conditions (14) F332 medication error rate is not % or greater (12) level well-being () F31 - services to restore normal bladder function and prevent infection () F22 - investigate allegations abuse (9) F278 ASSESSMENT MUST ACCURATELY REFLECT RESIDENT STATUS (8) F329 - drug regimen is free unnecessary drugs (7) F323 - supervision to prevent (13) pressure ulcers (12) F282- Services meet pressional standards/provided in accordance with care plan (9) F329 - drug regimen is free unnecessary drugs (9) F280 - periodically review and revise the plan care (8) prepare, and serve food under sanitary conditions (8) F42 - MEDICATION SYSTEM ASSURES ACCURATE RECEIPT/ ADMINISTRATION (8) F22 - investigate allegations abuse (7) F318 SERVICES TO INCREASE RANGE OF MOTION OR PREVENT DECLINE IN ROM (7) F334 OFFER INFLUENZA AND PNEUMOCOCCAL VACCINE () ITALICS not in State s Top Ten BLUE/SMALL CAPS -new to Top Ten compared to entity s data