Beaver Dam Health Care Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

On 11/13/25, at 08:00AM, Surveyor interviewed NP D (Nurse Practitioner). NP D indicated she would expect a medical provider to be notified whether it be the wound care team, physician, or NP of wound care not being completed due to refusal or not in facility or whatever the reason may be for wound care not being completed.

On 11/13/25, at 10:00AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what blanks on TAR indicate. DON B indicated it was not completed. Surveyor asked DON B if it is his expectation that physician orders be followed. DON B indicated yes. Surveyor asked DON B if physician should be notified if wound care is not completed due to refusal or not being in facility or whatever the reason be for wound care not being completed. DON B indicated he would expect physician to be notified.

Surveyor informed DON B of Resident R3's missed treatments indicated on Resident R3's TAR. DON B indicated he would look for documentation regarding missed treatments. DON B came back later to Surveyor and indicated he was unable to find documentation regarding missed tr Example 3:

The facility's policy Vital Signs, dated 3/1/19, includes: 3. Vital signs shall be obtained at least in the following circumstances: c. At least daily for a resident receiving skilled services.

The facility's policy Charting and Documentation, dated 7/17, includes: All services provided to the resident, progress toward the care plan goals.shall be documented in the resident's medical record. The following information is to be documented in the resident medical record: c. Treatments or services performed; f.

Progress toward or changes in the care plan goals and objectives. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; Resident R2 admitted to the facility on [DATE REDACTED] with a diagnosis of sepsis (overwhelming immune response to an infection). Resident R2's physician orders include:Daptomycin Intravenous Solution 500 mg. Use 950 mg intravenously one time a day for infection for 33 administrations. Order date 10/9/25. Resident R2's comprehensive care plan includes Focus: Active infection. Endocarditis r/t (Related To) Enterococcus with IV antibiotic treatment. Resident R2's Weights and Vitals Summary include blood pressure, pulse, and temperature was obtained on 10/9/25, 10/10/25, 10/11/25, 10/12/25, 10/22/25, and 10/24/25.

Of note: Resident R2 did not have daily vitals while receiving antibiotic therapy. Resident R2's Skilled Charting Note UDA (User Defined Assessment) was completed on 11/11/25 and 11/12/25.

On 11/12/25 at 2:26 PM, Surveyor interviewed DON B (Director of Nursing) regarding assessments and skilled services. DON B indicated IV antibiotics and therapy would be considered skilled services. DON B indicated a resident on IV antibiotics and therapy should have documented daily vital signs and an assessment. DON B indicated Resident R2 should have had daily vital signs and an assessment but did not. Resident R2 did not have daily assessments while receiving antibiotic therapy.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beaver Dam Health Care Center

410 Roedl CT Beaver Dam, WI 53916

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident R2) reviewed for medications.Resident R2 did not have the correct order for his Gabapentin (medication to treat nerve pain).This is evidenced by:The facility's policy Preventing and Detecting Adverse Consequences and Medication Errors, dated 10/25/14, includes: When a resident receives a new medication, the medication order is evaluated for the following: 1) The dose, rout of administration, duration, and monitoring are in agreement with the current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.Resident R2 admitted to the facility on [DATE REDACTED] with a diagnosis of polyneuropathy (damage or disease affecting peripheral nerves).Resident R2's hospital discharge paperwork, dated 10/9/25, includes an order for Gabapentin 100 mg capsule take 1 capsule by mouth every 8 hours. Of note, every 8 hours would be three times a day.Resident R2's active physician orders, printed 11/13/25, includes Gabapentin 100 mg capsule. Give 1 capsule by mouth two times a day for pain.

Scheduled at 8:00 AM and 4:00 PM. Order date 10/9/25. On 11/13/25 at 8:00 AM, Surveyor interviewed NP D (Nurse Practitioner) regarding Resident R2's Gabapentin order. NP D indicated she did not change Resident R2's Gabapentin order and the medication should have been given three times a day.On 11/13/25 at 8:58 AM, Surveyor interviewed UM C (Unit Manager) regarding entering medication orders. UM C indicated if Resident R2's hospital discharge paperwork included an order for every 8 hours, the medication should have been put in for 3 times a day.On 11/13/25 at 10:00 AM, Surveyor interviewed DON B (Director of Nursing) regarding medication orders. DON B indicated if the hospital discharge paperwork included an order for every 8 hours, the medication should have been put in for 3 times day. DON B indicated this was a medication error.

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