Bedrock Hcs At Beaver Dam Llc

F-F600.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41788

Residents Affected - Few Based on observation, interview and record review the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 1 resident (Resident R5) reviewed for gastrostomy tube (G/T, or G-Tube) care.

Resident R5 had a G-Tube placed 11/8/24 and currently does not use it. Resident R5 does not receive the appropriate care and treatment as ordered to G-Tube to maintain the patency.

Evidenced by:

The facility policy entitled, Enteral Nutrition, dated January 2025, states, in part: . Policy Statement: Adequate nutritional support through enteral feeding will be provided to residents as ordered.

Policy Interpretation and Implementation: .

6. If the resident has a feeding tube placed prior to admission or returning to the facility, the Physician and

the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident .

13. Staff caring for residents with feeding tubes will be trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as: .

b. Leaking and skin breakdown around insertion site .

Resident R5 was admitted to the facility on [DATE REDACTED] and has diagnoses that include hemiplegia (a medical condition characterized by paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and dysphagia (difficulty swallowing).

Resident R5's Discharge Summary, dated 12/17/24, states, in part: .

admitted : 11/22/24 discharge date : 12/13/24 .

Primary Discharge Diagnoses: Left middle cerebral artery stroke (occurs when blood flow to the left side of

the MCA, a major artery in the brain, is interrupted) .

Secondary Discharge Diagnoses: .

Dysphagia (difficulty swallowing)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0693 Presence of externally removable percutaneous endoscopic gastrostomy (PEG) tube (a thin, flexible tube inserted through the skin and the stomach used to provide nutrition and medications to people who cannot Level of Harm - Minimal harm or eat or drink adequately) . potential for actual harm Discharge Disposition: . Residents Affected - Few For Skilled Nursing Facility: .

-Maintain patency of G-Tube with frequent flushes .

Details of Hospital Stay: .

G-Tube was placed 11/15 given ongoing dysarthria/dysphagia .

Dysphagia: .

-Assessment & Plan

SLP (Speech-Language Pathologist) eval and treat.

VFSS (Videofluoroscopic swallow study) 12/8 with upgrade to general diet with thin liquids.

Continue with supervision with meals.

Tube Feedings discontinued, monitor PO (by mouth) intake, ongoing every 8-hour flushes for g-tube patency .

(Of note, Resident R5's discharge paperwork indicated on going every 8 hour flushes for patency, and this was never transcribed or clarified)

Resident R5's Treatment Administration Record (TAR) for months of December, January, and February do not have g-tube orders to monitor and flush.

Resident R5's TAR for March include:

-Monitor G-tube site for redness or signs of infection. Clean with soap and water and apply gauze around site. Every shift for tube feeding. Order Date: 3/20/25 2:31PM

Resident R5's Order Summary Report, dated 3/20/25, include: .

-Monitor G-Tube site for redness or signs of infection. Clean with soap and water and apply gauze around site. Every shift for tube feeding. Order Status: 3/20/25. Start Date: 3/20/25 .

(Important to Note: this order was to be started on 3/20/25, Resident R5 did not have an order on the Medication Administration Record (MAR)/TAR prior to Survey on 3/20/25.)

Resident R5's Care Plan, dated 3/20/25, states, in part: .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0693 Focus: Tube Feeding tube in place r/t (related to) possible need r/t stroke and possible supplement if poor intake occurs. Date Initiated: 3/20/25. Level of Harm - Minimal harm or potential for actual harm Goal: Maintain nutritional status and body weight. Date Initiated: 3/20/25. Target Date: 6/23/25.

Residents Affected - Few Interventions:

*Check tube placement when flushing. Date Initiated: 3/20/25. Revision on: 3/30/25 .

*G-tube site cares daily per MD (Medical Doctor) order. Date Initiated: 3/20/25 .

*Observe and report skin irritation at the tube site. Date Initiated: 3/20/25 .

Important to note: The feeding tube care plan was initiated on 3/20/25. Prior to 3/20/25 Resident R5 did not have a feeding tube care plan.

On 3/20/25 at 2:15 PM, Surveyor and DON B (Director of Nursing) observed Resident R5's G-Tube site. DON B described the site as having thick, mucousy drainage around the tube site with some dried dark red drainage around that. DON B indicated it should be getting cleaned and monitored.

On 3/20/25 at 11:05 AM, CNA F (Certified Nursing Assistant) indicated the nurses do not do anything to Resident R5's G-tube, and Resident R5 and his wife have asked for the tube to be removed.

On 3/20/25 at 12:47 PM, CNA E indicated to Surveyor that the nurses do not do anything with Resident R5's G-tube. CNA E indicated Resident R5 does not use the G-tube.

On 3/20/25 at 2:01 PM, Surveyor showed DON B the order to maintain patency of G-Tube with frequent flushes and asked what the expectations would be for the order. DON B indicated she would expect more specific instructions from MD on how frequent. DON B indicated Resident R5 should be receiving cares to G-Tube site along with monitoring for infection and frequent flushes to keep it patent. Surveyor asked DON B if Resident R5 should have a G-Tube care plan and orders on TAR for nurses to follow, and DON B indicated yes.

On 3/20/25 at 2:39 PM, ADON C (Assistant Director of Nursing) indicated she would expect nurses to be checking Resident R5's G-Tube placement and maintain patency. ADON C indicated she would expect physician orders to be followed.

On 3/20/25 at 2:40 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) and asked what interventions are in place for Resident R5's G-Tube. LPN D indicated she does not do anything with Resident R5's G-Tube; there is nothing on Resident R5's TAR. LPN D indicated nurses should be flushing the G-Tube and checking for patency even if the G-Tube is not being used.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50285 potential for actual harm Based on interview and record review, the facility did not ensure that pain management was provided to Residents Affected - Few residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident R6) reviewed for pain.

Resident R6 was admitted to the facility with rhabdomyolysis (a condition where muscle tissue breaks down, causing sever muscle pain, tenderness, and muscle cramps). The facility failed to obtain Resident R6's pain medication, and failed to offer Resident R6 any non-pharmacological interventions to treat her pain, resulting in Resident R6 having continued pain.

Evidenced by:

The facility policy titled Pain Management, dated 10/1/22, states in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences . Recognition: . Facility staff will observe for nonverbal indicators which may indicate the presence of pain.

These indicators include but are not limited to . b. Loss of function or inability to perform activities of daily living (ADLs) . e. Behaviors such as: . depressed mood or decreased participation in usually physical and/or social activities . h. Difficulty sleeping (insomnia) . i. Negative vocalizations (e.g. groaning, crying .), j. Decline

in activity level . Pain Assessment: . 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g. nurses, practitioner, pharmacists and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident . g. Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain. h. Impact of pain on quality of life (e.g. sleeping, functioning, appetite and mood) . j. The resident's goals for pain management and his/her satisfaction with

the current level of pain control . Pain Management and Treatment: . 6. Non-pharmacological interventions will include but are not limited to . a. Environmental comfort measures . d. Physical modalities . e. Exercises to address stiffness . as well as restorative programs to maintain joint mobility . f. Cognitive/behavioral interventions . 7. Pharmacological interventions . The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain . i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen .

Resident R6 was admitted to the facility on [DATE REDACTED] with diagnoses that include Morbid obesity, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), Insomnia, Essential Hypertension, Major Depressive Disorder, and Rhabdomyolysis. Resident R6's Brief Interview for Mental Status (BIMS) dated 1/30/25 was 15 out of 15, indicating that Resident R6 is cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0697 Resident R6's Care Plan states, in part: Focus: Needs pain management and monitoring related to migraine headache and chronic pain. Date initiated: 1/20/25. Goal: Patient will achieve acceptable pain level goal of 4. Date Level of Harm - Minimal harm or initiated: 1/20/25. Interventions: Administer pain medication as ordered. Date initiated. 1/20/25 . Evaluate potential for actual harm characteristics and frequency/pattern of pain. Date initiated: 1/20/25 . Evaluate need to provide medications prior to treatment or therapy. Date initiated: 1/20/25 . Evaluate what makes the patient's pain worse. Date Residents Affected - Few initiated: 1/20/25 .

Resident R6's Physician Orders include the following pain medications:

Acetaminophen Oral Tablet 325 mg (milligrams). Give 2 tablet by mouth every 4 hours as needed for pain. Not to exceed 4000 mg in a 24 hour period. Start Date: 1/23/25. No end date.

Cyclobenzaprine HCl Oral Tablet 10 mg. Give 1 tablet by mouth every 12 hours as needed for muscle spasms. Start Date: 1/23/25. No end date.

Diclofenac Oral Capsule. Give 75 mg by mouth two times a day for pain. Start Date: 3/14/25. No end date.

Lidocaine External Patch 5%. Apply patches to affected area topically one time a day for pain. Bilateral shoulders and lower back and remove per schedule. Start Date 3/26/25. No end date.

Morphine Sulfate Oral Tablet 15 mg. Give 7.5 mg by mouth every 6 hours as needed for pain. Start Date: 2/4/25. No end date.

Pregabalin Oral Capsule 225 mg. Give 1 capsule by mouth three times a day for pain. Start Date: 1/23/25. No end date.

Sumatriptan Succinate Oral Tablet 50 mg. Give 1 tablet by mouth every 2 hours as needed for migraine. Take one tablet orally PRN, may repeat 1 dose in 2 hours, not to exceed 2 tablets in 24 hours. Start Date: 1/23/25. No end date.

Trolamine Sallcylate External Cream 10%. Apply to affected area topically every 24 hours as needed for moderate pain. Start Date: 1/23/25. No end date.

Resident R6's March 2025 Medication Administration Record (MAR) documents the following:

Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain was marked with an X and 7 beginning on 3/14/25 through 3/20/25 when surveyors were onsite. The chart code 7 indicates Other/See Nurse Progress Note.

Resident R6's Nurse Progress Notes state the following:

3/14/25 at 2:05 PM: MD (Medical Director) updated diclofenac potassium tablet 25 mg was not available on 3/13/25 as scheduled and would be available later tonight MD with no new orders except to consider hospice for pain.

3/15/25 at 1:09 PM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. Medication to be delivered tonight.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0697 3/15/25 at 5:32 PM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. Med on order from pharmacy. Level of Harm - Minimal harm or potential for actual harm 3/16/25 at 9:36 AM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. Med on order from pharmacy. Residents Affected - Few 3/16/25 at 5:20 PM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. Med on order from pharmacy.

3/17/25 at 9:03 AM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. On order.

3/17/25 at 5:26 PM: NP (Nurse Practitioner) notified of missing Diclofenac medication. No new orders. Awaiting pharmacy approval to send.

3/18/25 at 9:17 AM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. Waiting for pharmacy to deliver and insurance to give authorization. MD aware.

3/18/25 at 5:01 PM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. Med on order from pharmacy.

3/19/25 at 7:05 AM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. On order from pharmacy.

3/19/25 at 5:17 PM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. Waiting for pharmacy to deliver and insurance to give authorization. MD aware.

3/20/25 at 2:50 PM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. On order since 3/15.

3/20/25 at 5:22 PM: Diclofenac Oral Capsule give 75 mg by mouth two times a day for pain. On order from pharmacy.

Daily pain monitoring every shift states the following:

3/14/25 pain scale:

Day Shift: 9 out of 10 pain rating

Evening Shift: 5 out of 10 pain rating

Night Shift: 6 out of 10 pain rating

3/15/25 pain scale:

Day Shift: 9 out of 10 pain rating

Evening Shift: 5 out of 10 pain rating

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0697 Night Shift: 6 out of 10 pain rating

Level of Harm - Minimal harm or 3/16/25 pain scale: potential for actual harm Day Shift: 5 out of 10 pain rating Residents Affected - Few Evening Shift: 5 out of 10 pain rating

Night Shift: 0 out of 10 pain rating

3/17/25 pain scale:

Day Shift: 9 out of 10 pain rating

Evening Shift: 0 out of 10 pain rating

Night Shift: 0 out of 10 pain rating

3/18/25 pain scale:

Day Shift: 8 out of 10 pain rating

Evening Shift: 5 out of 10 pain rating

Night Shift: 0 out of 10 pain rating

3/19/25 pain scale:

Day Shift: 8 out of 10 pain rating

Evening Shift: 3 out of 10 pain rating

Night Shift: 0 out of 10 pain rating

3/20/25 pain scale:

Day Shift: 10 out of 10 pain rating

Evening Shift: 5 out of 10 pain rating

It is important to note that Resident R6 had orders for acetaminophen and morphine (as needed) for pain, and did utilize these for pain during this time period.

On 3/20/25 at 11:06 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) who stated that Resident R6 was always in pain. CNA F stated that Resident R6 told her that the pain was excruciating. CNA F stated that she tells the nurse on duty right away when Resident R6 complains of pain, but that some of the nurses are not real timely about going to assess the residents and if a resident is getting scheduled pain medication, the nurses do not have

a sense of urgency and will say I will get there when I get there.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0697 On 3/20/25 at 12:47 PM, Surveyor interviewed CNA E who stated that Resident R6 is in a lot of pain every day, crying every day due to the amount of pain she is in. CNA E said that she tells the nurses right away about Resident R6's Level of Harm - Minimal harm or pain, and that sometimes they are pretty quick about responding, and other times Resident R6 will have to put on her potential for actual harm call light and ask a second time for pain medication.

Residents Affected - Few On 3/20/25 at 1:51 PM, Surveyor interviewed Resident R6, who stated she was in lots of pain all over and that she was receiving morphine and diclofenac for the pain. Resident R6 explained that she has a compressed nerve in her neck and had experienced back issues most of her life. Resident R6 stated that she had a fall in her apartment before coming to the facility in which an EMT (Emergency Medical Technician) damaged muscles in her groin when lifting her off the floor. Resident R6 indicated that she used to be able to walk and now cannot. Resident R6 stated, it gets depressing being in this much pain and having to just put up with it. Surveyor asked Resident R6 what her pain rating was at that moment. Resident R6 stated her pain was a 9 but that it never goes below an 8. Surveyor asked if Resident R6 had spoken with management about her pain not being well managed. Resident R6 stated she had talked to NHA A (Nursing Home Administrator) and DON B (Director of Nursing) many times. Resident R6 indicated that she cries every day because of the pain and that the medication she receives barely takes the edge off her pain.

It is important to note that Resident R6 stated she was receiving diclofenac as part of her pain regimen and was not aware that she was not actually receiving this medication.

On 3/20/25 at 2:04 PM, Surveyor notified RN K (Registered Nurse) about Resident R6 having a pain rating of 9. RN K indicated she would see what Resident R6 could get for pain, but she had already gotten a PRN morphine earlier.

On 3/20/25 at 2:40 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) who stated that although Resident R6's pain varies, there are times that she is in a significant amount of pain and is tearful. Surveyor asked LPN D what she would do if a resident was in a significant amount of pain. LPN D indicated that she would assess the resident and then review the MAR to see what kind of PRN medications the resident had ordered.

On 3/20/25 at 4:18 PM, Surveyor interviewed Resident R6 who stated that both NHA A and DON B were aware that

she was in a lot of pain. Surveyor asked if staff ever offered her any non-pharmacological interventions, such as music therapy, hot or cold packs, or massage. Resident R6 stated that no one had ever offered her any non-pharmacological interventions for treatment of her pain. Resident R6 stated that most nights she can't sleep due to the pain, and just lays awake and cries.

On 3/20/25 at 4:21 PM, Surveyor interviewed MT G (Medication Technician). Surveyor asked MT G what the process would be if a resident was missing a medication. MT G stated that she would put in an order for the pharmacy and then call the pharmacy to make sure it is coming in the next shipment. Surveyor asked MT G what the process would be if the medication did not come when it was supposed to. MT G stated that she would call the pharmacy again and try to get the meds stat (immediately) but that the facility pharmacy is in Chicago, so it sometimes takes awhile to get the needed medications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0697 On 3/20/25 at 5:34 PM, Surveyor interviewed DON B, who stated that Resident R6 was not receiving the diclofenac because it was being denied due to insurance coverage. DON B indicated that the doctor was aware of it Level of Harm - Minimal harm or and looking into the issue. DON B stated that every time it is re-ordered, it requires an authorization. potential for actual harm Surveyor asked DON B what non-pharmacological interventions had been tried with Resident R6 to help manage her pain. DON B said they give Resident R6 PRN Tylenol and have a referral to the pain management clinic. Residents Affected - Few

On 3/20/25 at 7:17 PM, Surveyor interviewed NHA A and asked him if he was aware that Resident R6 had reported daily pain at a 9 or a 10 and had been missing one of her physician prescribed pain medications for almost a week. NHA A stated he was not aware that Resident R6 was missing medications, but that he did know that Resident R6 had requested a hospice referral because she was in so much pain. Surveyor asked NHA A if he would expect that the resident would receive all of their prescribed medications. NHA A stated he would have to talk with DON B.

Facility failed to follow-up with the MD regarding a missing pain medication, the facility did not provide adequate pain management for a resident with chronic daily pain. The facility did not develop or implement non-pharmacological interventions or approaches, and did not follow the resident's plan of care, current professional standards of practice, and the resident's goals and preferences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 17 525338

F-F609.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50285

Residents Affected - Few Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 2 of 2 abuse allegations involving Residents (Resident R3 and Resident R6).

CNA F (Certified Nursing Assistant) reported an abuse allegation involving CNA I and Resident R3 that occurred on 3/20/25 to NHA A (Nursing Home Administrator).

Resident R6 reported multiple incidents of CNA I mocking her accent to NHA A. These incidents were not treated as abuse and were not reported to the state agency.

Evidenced by:

Facility policy entitled Abuse/Neglect/Exploitation, undated, states, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or thing their hearing distance regardless of their age, ability to comprehend, or disability . Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . Neglect meals failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents . 3. The facility will provide ongoing oversight and supervision of staff in order to assure its policies are implemented as written . VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . 2. Assuring that reporters are free from retaliation or reprisal .

Example 1

Resident R3 was admitted to the facility on [DATE REDACTED]. Resident R3's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/18/25, indicates Resident R3 has a Brief Interview of Mental Status (BIMS) of 10 out of 15, indicating Resident R3 has moderate cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0609 On 3/20/25 at 11:06 AM, during an interview with CNA F (Certified Nursing Assistant), who stated that when

she came in that morning, she found CNA I and Resident R3 in the lounge. Resident R3 was in her wheelchair in the lounge Level of Harm - Minimal harm or wearing an incontinence brief and t-shirt but no pants. CNA I was telling Resident R3 that she was disrespectful, that potential for actual harm she was on her call light all the time, and that she was going to file a grievance against Resident R3 with the facility. CNA I told Resident R3 that if she would have stayed in bed she wouldn't have fallen, and told Resident R3 she should not have Residents Affected - Few come out to the lounge. Resident R3 was crying and stated she would just go hide in my room. At this point CNA F intervened, telling CNA I she could go home, and she would help Resident R3. Resident R3 stated she was trying to put on her compression stockings and fell out of her wheelchair because no one would help her. CNA F said that Resident R3 was terrified of CNA I. Surveyor asked CNA F if she would consider what happened this morning as abuse. CNA F stated yes, it was an allegation of abuse and that she followed the facility abuse policy by calling NHA

A (Nursing Home Administrator) at home right away.

Please note: CNA F indicated throughout this exchange, CNA I was loudly berating Resident R3 who was crying and visibly upset.

On 3/20/25 at 12:47 PM, Surveyor interviewed CNA E, who said she saw the incident that happened that morning between CNA F, CNA I, and Resident R3. CNA E stated that she observed CNA I say something to Resident R3 and then CNA F told CNA I not to talk to Resident R3 that way and that she should just go home since her shift was over. CNA E stated she did not hear what exactly CNA I said to Resident R3, only CNA F intervening and telling CNA I not to talk to Resident R3 that way. CNA E indicated that she would consider the way CNA I treated Resident R3 as abuse. CNA E stated that Resident R3 was afraid of CNA I and says that CNA I refuses to take her to the bathroom at night. Surveyor asked CNA E if she had ever reported this allegation of abuse to the administration. CNA E stated no, she had not.

On 3/20/25 at 7:09 PM, Surveyor interviewed RN J (Registered Nurse) who stated that she saw the entire incident between CNA I and CNA F. RN J stated that CNA F and CNA I were raising their voices and getting Resident R3 all worked up. RN J stated she would consider what happened to Resident R3 as psychological abuse. Surveyor asked RN J if she had told anyone about the psychological abuse she had witnessed. RN J stated no, she hadn't because everyone saw what happened.

Example 2

Resident R6 was admitted to the facility on ,d+[DATE REDACTED] Resident R6's most recent MDS, with an ARD of 1/30/25, indicates Resident R6 has a BIMS of 15 out of 15, indicating Resident R6 is cognitively intact.

On 3/20/25 at 10:19 AM, Surveyor spoke with Resident R6 who stated that CNA I makes fun of her accent and the way she talks. Resident R6 said she feels belittled by CNA I, and there are many nights she can't sleep and just lies awake in bed and cries because of her pain, immobility, and having CNA I make fun of her on top of everything else that she is experiencing. Resident R6 stated that many nights she will put on her call light, and CNA I will turn off her call light and tell her she will come right back, but that she doesn't come back for over an hour, resulting in her being soaked and getting a rash. Resident R6 stated that she had talked to NHA A on more than one occasion about CNA I, her lack of care, and how she made fun of her accent, but that nothing was ever done about it.

On 3/20/25 at 1:18 PM, Surveyor interviewed NHA A, who stated that he had received no reportable incident from today.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 17 525338 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525338 B. Wing 03/20/2025

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 0609 On 3/20/25 at 7:17 PM, Surveyor interviewed NHA A who stated that no one had ever reported concerns about CNA I. Surveyor asked NHA A if Resident R6 had ever brought concerns to him about lack of care with CNA I Level of Harm - Minimal harm or and that CNA I makes fun of her accent. NHA A stated that he had talked to Resident R6's sister, and that her memory potential for actual harm has been going a little and she will say things happened that really didn't. Surveyor pointed out that Resident R6 has a BIMS of 15 and no dementia diagnosis. Surveyor asked NHA A if he should take all allegations of abuse Residents Affected - Few seriously. NHA A replied yes absolutely. Surveyor pointed out that Resident R3 and Resident R6 do not feel safe in their own home. NHA A agreed that Resident R3, Resident R6, and all the residents should feel safe in their home.

(Of note: NHA A was aware that Resident R6 had voiced concerns.)

The Facility failed to foster an environment where staff and others felt free to report all alleged violations of mistreatment, exploitation, neglect, or abuse without fear of retaliation, and failed to take all allegations of abuse seriously. The Facility failed to follow their abuse policy and did not report these accusations of abuse to the state agencies within the required timeframe.

Cross Reference