Juliette Manor

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

that CNA-D always tells Resident R1 to piss in Resident R1's brief. CNA-C stated Registered Nurse (RN)-E entered Resident R1's room seconds after CNA-D left and was also aware that CNA-D yelled at Resident R1 and did not provide assistance.

CNA-C reported that Resident R1 told RN-E that staff told Resident R1 to piss in Resident R1's brief. CNA-D finished the shift and left for the day. CNA-C went home and was still bothered by the incident. CNA-C returned to the facility the same day (8/27/25) at approximately 1:00 PM to complete training and reported the incident to RN-F at approximately 3:00 PM. CNA-C verified CNA-C should have reported the incident sooner. On 9/10/25 at 3:21 PM, Surveyor interviewed NHA-A, Director of Nursing (DON)-B, and RN-F via phone conference.

DON-B indicated CNA-C reported the incident to RN-F. RN-F confirmed CNA-C reported the incident to RN-F on 8/27/25 at approximately 4:00 PM. RN-F immediately educated CNA-C regarding reporting requirements and told CNA-C that CNA-C should have reported the incident to administration immediately.

On 9/10/25 at 4:08 PM, Surveyor interviewed Regional Nurse Consultant (RNC)-G who stated the facility's policy indicates if there is no serious bodily injury, the facility has up to 24-hours to report. Surveyor informed RNC-G of the regulation and reviewed the facility's policy with RNC-G. The facility's policy indicates for alleged violations of abuse, OR if there is serious bodily injury, the facility must report the allegation to the SA immediately but no later than two hours after the allegation is made. RNC-G acknowledged the verbiage in the policy and confirmed the facility's investigation substantiated that abuse occurred.

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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

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Juliette Manor

482 Oak Street Berlin, WI 54923

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

date of 8/14/25. SSD-I stated the education was completed a week prior to 8/27/25 as a result of another incident. SSD-I stated additional education was not completed following the 8/27/25 incident because the facility had just educated staff.On 9/10/25 at 3:21 PM, Surveyor interviewed NHA-A, DON-B, and RN-F via phone conference. RN-F stated CNA-C reported the incident to RN-F on 8/27/25 at approximately 4:00 PM and RN-F immediately reported the incident to DON-B. RN-F immediately educated CNA-C regarding reporting requirements and told CNA-C that CNA-C should have reported the incident to administration immediately. NHA-A stated the facility educated specific staff who worked on 8/27/25 and provided reeducation through a nursing meeting. Surveyor requested to see the all staff education.On 9/10/25 at 4:08 PM, Regional Nurse Consultant (RNC)-G provided Surveyor with a Nursing Meeting Agenda. Surveyor reviewed the Nursing Meeting Agenda notes, dated 9/3/25 and 9/5/25, which indicated the following was discussed:Importance of maintaining professionalism in all interactions.Addressing challenges: tone, respect, accountability.Customer service expectations.Abuse reporting and resident rights.Surveyor reviewed staff signatures and noted CNA-C and RN-E's signatures were not listed. RNC-G showed Surveyor CNA-C and RN-E's signatures from the 8/18/25 education. When Surveyor asked the date that CNA-C and RN-E reviewed and signed the education, RNC-G stated RNC-G did not know when CNA-C and RN-E completed the education.RNC-G also provided Surveyor with a copy of the facility's LTC Behavioral Disturbance Policy and 3 copies of the LTC Resident Abuse Prevention and Reporting Policy.

RNC-G indicated the policies were reviewed with CNA-C, RN-E, and CNA-H. Surveyor reviewed the documentation and noted the following:The LTC Behavioral Disturbance Policy intended for CNA-C's education stated on the last page the education was completed by DON-B via phone on 8/27/25. Education was completed by RN-F in person on 8/27/25. The document included signatures from DON-B and RN-F.

The document did not include signed confirmation that CNA-C received and understood the education.The LTC Resident Abuse Prevention and Reporting Policy intended for CNA-C's education stated on the last page the education was completed by DON-B via phone on 8/27/25. Education was completed by RN-F in person on 8/27/25. The document included signatures from DON-B and RN-F. The document did not include signed confirmation that CNA-C received and understood the education.The LTC Resident Abuse Prevention and Reporting Policy intended for CNA-H's education stated on the last page the education was completed with CNA-H on 8/27/25 as part of corrective action and signed by RN-F. The document did not include signed confirmation that CNA-H received and understood the education.The LTC Resident Abuse Prevention and Reporting Policy intended for RN-E's education stated on the last page the education was completed with RN-E on 8/27/25 and signed by DON-B. The document did not include signed confirmation that RN-E received and understood the education.On 9/10/25 at 4:08 PM, Surveyor interviewed RNC-G who stated the facility's policy indicates the facility has up to 24-hours to report. Surveyor informed RNC-G of the regulation and reviewed the facility's policy with RNC-G. The facility's policy states for alleged violations of abuse, the facility must report the allegation to the SA immediately but no later than two hours

after the allegation is made or known. RNC-G acknowledged the regulation and policy. Surveyor reported to RNC-G that CNA-C reported continued instances after 8/27/25 of concerns with call light response times and staff telling residents to urinate in their briefs. RNC-G acknowledged the concern with staff retention regarding abuse prevention and reporting.

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