Congregational Home, Inc

F-F689) Congregational Home will provide an environment that is free from hazards over which the facility has control and will provide appropriate supervision to each resident to prevent avoidable falls. Under Procedure documents 10. The Charge Nurse caring for the resident that has fallen will complete the following forms: * Skilled Nursing Fall Incident Form A note from appropriate licensed and direct care staff providing care to the resident prior to fall and any witnesses if applicable. * With head trauma the Charge Nurse will complete Evaluation if the resident will require further medical work up and be transported to the Hospital emergency room . * Head Trauma Craniotomy Check Flow Sheet will be initiated with all unwitnessed falls. 11. The Charge Nurse will initiated an intervention help reduce risk of future falls. 12. The Charge Nurse will update POC (plan of care) and the CNA (Certified Nursing Assistant) Care Plan. 13. The Nurse Care Manager/RN (Registered Nurse) Supervisor on duty at time of fall will review all Charge Nurse follow up and documentation including: *Care plans. *Nursing notes. *And assure the new intervention/s and any ongoing interventions to prevent future falls are appropriate.

1.) Resident R2's diagnoses includes unspecified dementia severe with psychotic disturbances, anxiety disorder, epilepsy, atrial fibrillation, hypertension, and depressive disorder.

The Falls CAA (care area assessment) dated 6/28/24 documents under the analysis of findings for nature of problem/condition: Morse fall scale score of 19, High risk for falls. Hx (history) of 2 recent falls. See delirium, cognitive, communication, pain CAA for details. Dx (diagnosis) of new seizures, vascular dementia. BIMS (brief interview mental status) score 3/15. Less and less awareness of safety, ability limitations, non ambulatory. Full body lift for transfers up in Broda chair. PRN (as needed) oxycodone medication therapy. Polyneuropathy see NP (Nurse Practitioner) note 6/10/24.

Under the Care Plan Considerations section it documents: Newly assigned to hospice. Ongoing decline in mobility & strength, cognitive communication skills. Potential for falls. Goal is for comfort. No falls, injury. Nursing to anticipate and assist with mobility and ADL (activities daily living) deficits, monitor for safety 1:1 PRN (as needed), encouraging to be in a more supervised area. Bed canes for bed mobility, confusion and forgetful. Ensure has hearing aids. Thick full mat to side of bed. Dycem to recliner. Gripper socks. Check and change for incontinence cares. See falls care plan.

The Quarterly MDS (minimum data set) with an assessment reference date of 9/13/24 has a BIMS score of 3 which indicates that Resident R2 has severe cognitive impairment. Resident R2 has fallen since prior assessment with 2 or more falls, no injury and 2 or more with injury (except major).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 525700 Department of Health & Human Services Printed: 09/09/2025 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 525700 B. Wing 02/05/2025

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

Congregational Home, Inc 13900 W Burleigh Rd Brookfield, WI 53005

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 0689 The Quarterly MDS with an assessment reference date of 12/13/24 has a BIMS score of 3 which indicates severe impairment. Resident R2 is assessed as being dependent for toileting hygiene, roll left & right, & chair/bed to Level of Harm - Minimal harm or chair transfer. Resident R2 is assessed as always incontinent of urine and bowel. Resident R2 has fallen since prior potential for actual harm assessment with 2 or more falls, no injury and 2 or more with injury (except major).

Residents Affected - Few Resident R2's fall care plan initiated 6/1/24 and revised 9/27/24 documents the following interventions: *Continue interventions on the at risk plan initiated 6/1/24. *For no apparent acute injury, determine and address causative factors of the fall, initiated 6/1/24. *New Intervention post fall on 6/3/24: When resident is up out of bed to be in Broda chair for safety precautions, initiated 6/3/24. *New Intervention post fall on 6/25/24: Increased frequency of check and change to: Check and Change every 2 hours and as needed, initiated 6/25/24. *New Intervention post fall on 6/26/24: Staff to perform safety checks on resident every 30 minutes for safety measures and fall prevention, initiated 6/26/24. *New Intervention post fall on 7/1/24: Staff to follow residents current toileting plan: Staff to check and change resident every 2 hours and PRN (as needed), initiated 7/9/24 & revised 2/4/25. *State X-ray to left post UWF (unwitnessed fall) on 7/1/24 d/t (due to) raised red firm area of skin to top of left foot. X-Ray Impression Left Foot: No acute abnormality is seen involving

the left foot, initiated 7/1/24. *New Intervention post fall on 7/3/24: Reviewed residents current behavioral medication with [Name] psych NP (Nurse Practitioner). Updated psych NP regarding resident continued anxiety/agitation/restlessness with frequent attempts made by resident to get up out of Broda chair resulting

in fall. Reviewed Behavioral medication regimen with [Name] psych NP with new orders obtained on 7/3/24 for: Depakote 250 mg (milligrams) BID (twice daily) along with new orders for CBC (complete blood count) & CMP (comprehensive metabolic panel) on 7/8/24, initiated 7/3/24. *Ensure Broda chair is slightly reclined when resident is in Broda chair, initiated 7/24/24. *New Intervention Post fall on 7/24/24: Ensure Broda chair is slightly reclined when resident is in Broda chair, initiated 7/24/24. *New Intervention post fall on 7/24/24: If resident becomes restless have staff first check if resident needs her briefs changed. Resident is frequently restless when her briefs are soiled or when she has to have a BM (bowel movement), initiated 7/25/24. *Intervention 7/29/24: Educated activities staff if resident becomes restless during an activity please notify nursing staff so resident can be toileted. If resident becomes restless have staff first check if resident needs her briefs changed. Resident is frequently restless when her briefs are soiled or when she has to have a BM (bowel movement). Staff also educated when resident is up in Broda chair to be slightly reclined d/t Broda chair wasn't reclined on 7/29/24 when fall occurred, initiated 8/9/24. *New Intervention 8/5/24: Nursing staff educated on importance of reading resident care cards at the start of every shift to make sure all interventions are being followed appropriately, initiated 8/5/24 and revised 2/4/25. *Thick fall mat on side of bed when occupied and unattended, initiated & revised 9/4/24. *Intervention post fall on 9/11/24: Reviewed psychotropic medication regimen at behavioral health meeting with [Name] psych NP on 9/12/24 with new & changed psychotropic medications orders obtained per psych NP to decrease residents current behaviors including decreased anxiety/agitation with decreased falls r/t (related to) restless behaviors, initiated 9/12/24. *Monitor/document/report PRN x (times) 72h (hour) to D for s/sx (signs/symptoms): Pain, bruises, Changes

in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation, initiated 9/11/24 & revised 9/27/24. *Neuro-checks x (times) Q15min (every 15 minutes) x 4, Q1hr x 4, Q4 hrs x 4, Q8 hrs x 4 per facility protocol, initiated 9/11/24 & revised 9/27/24. *Vital signs x 15 min x 4, 1 hr x 4, Q4 hrs x 4, Q8hrs x 4 per facility protocol, initiated 9/11/24 & revised 9/27/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 525700 Department of Health & Human Services Printed: 09/09/2025 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 525700 B. Wing 02/05/2025

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

Congregational Home, Inc 13900 W Burleigh Rd Brookfield, WI 53005

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 0689 The Broda Operating Manual Centric Tilt Semi Recliner provided to Surveyor on 2/5/25 by DON (Director of Nursing)-B under the section 2.5 Hazards for 2.5.1 Position of Chair - Danger of Falling documents After a Level of Harm - Minimal harm or resident is transferred into a chair, assess the amount of tilt required. We recommend that the chair's seat be potential for actual harm tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. Residents Affected - Few Resident R2's incident note dated 7/22/24 at 11:03 a.m. and written by LPN (Licensed Practical Nurse)-P documents: Date, Time and Location of Fall: 7/22/24 at 0750 (7:50 a.m.) in the common TV area on west hall. Vitals, including POX (pulse oximetry), Blood Sugar and Orthostatic BP (blood pressure): BP: 148/91, P (pulse): 103, R (respirations) 16, POX: 93% RA (room air), T (temperature): 97.4. Describe the fall: Writer was called to the common TV area on west hall d/t (due to) resident slid out of her Broda chair on to the floor in front of her chair. Were there any injuries? If so, describe: No injuries noted. Date/Time/Name of Physician Update: 7/22/24, 0830 (8:30 a.m.) [Name] NP. Date/Time/Name of Family update: 7/22/24 0800 (8:00 a.m.) [Name] daughter POA (power of attorney).

Resident R2's fall on 7/22/24 was not thoroughly investigated as there was no CNAs (Certified Nursing Assistant) statements on the post fall report . There were no statements as to who last saw Resident R2 or what was Resident R2 doing.

The post fall report or the IDT (interdisciplinary team) incident follow up did not indicate whether prior interventions were in place at the time of the fall. The facility implemented a new intervention of ensure Broda is slightly in the reclining position. Resident R2's fall care plan was not revised with this intervention until 7/24/24 after Resident R2 had another fall. In addition, according to the manufacturers information recommend the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward. There is no documentation as to the tilt of Resident R2's Broda chair prior to the fall.

Resident R2's incident note dated 7/24/24 at 23:39 (11:39 p.m.) written by LPN-R documents Date, Time and Location of Fall: 7/24/24, 2015 (8:15 p.m.), [NAME] unit bird lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: See charted vitals. Describe the fall: Unwitnessed fall. Resident attempted to self transfer out of her Broda chair without staff assistance and fell on to the floor. Were there any injuries? If so, describe: No. Date/Time/Name of Physician Update: 7/24/24, 2044 (8:44 p.m.), [Name] Hospice. Date/Time/Name of Family update: 7/24/24, 2055 (8:55 p.m.) [Name] POA.

Resident R2's fall on 7/24/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw Resident R2 or what was Resident R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of Resident R2's Broda chair. New interventions included in the post fall report documents If resident becomes restless have staff first check if resident needs her briefs changed. Resident frequently restless when briefs soiled or when needs to have BM. Ensure Broda chair is slightly reclined when resident is up in Broda chair for safety. The intervention of checking Resident R2's incontinence product was placed on the fall care plan until 7/29/24, five days later and the intervention of reclining Resident R2's Broda chair was recommended after Resident R2's fall on 7/22/24. Resident R2's post fall report was not signed by the Nurse Manger until 8/6/24 and DON (Director of Nursing)-B did not sign

this report until 8/19/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 525700 Department of Health & Human Services Printed: 09/09/2025 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 525700 B. Wing 02/05/2025

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

Congregational Home, Inc 13900 W Burleigh Rd Brookfield, WI 53005

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 0689 Resident R2's incident note dated 7/29/24 at 15:19 (3:19 p.m.) written by LPN-Q documents Date, Time and Location of Fall: 7-29-24 1130 in TV room on west. Vitals, including POX, Blood Sugar and Orthostatic BP: 137/66, 97. Level of Harm - Minimal harm or 2, 76, 18, 925. Describe the fall: resident slid out of chair to the floor during activities. Were there any potential for actual harm injuries? If so, describe: no injuries. Date/Time/Name of Physician Update: 7-29-24 1225 (12:25 p.m.) [Physician name]. Date/Time/Name of Family update: 7-29-24 1225 (12:25 p.m.) [POA name]. Residents Affected - Few Resident R2's post fall report and IDT incident follow up for Resident R2's fall on 7/29/24 documents Resident R2's Broda chair wasn't reclined according to Resident R2's plan of care when Resident R2's fall occurred. There is no documentation as to whether other prior interventions were in place at the time of Resident R2's fall. Resident R2's post fall report was not signed by the Nurse Manger until 8/9/24 and DON (Director of Nursing)-B did not sign this report until 8/19/24.

Resident R2's incident note dated 8/5/24 at 15:38 (3:38 p.m.) written by LPN-J documents Date, Time and Location of Fall: 8/5/2024, 1430 (2:30 p.m.), canary lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: 132/74, 76, 16, 97.9, BG= (blood glucose equals) 118, 97%. Describe the fall: unwitnessed fall in canary lounge from Broda chair to the floor. Were there any injuries? If so, describe: no injuries. Date/Time/Name of Physician Update: [Name] NP. Date/Time/Name of Family update: [POA name], 8/5/2024, 1530 (3:30 p.m.).

Resident R2's post fall report 8/5/24 and IDT incident follow up dated 8/26/24 for Resident R2's fall on 8/5/24 includes documentation of Resident with frequent falls occurring d/t (due to) resident attempting to get up out of her Broda chair without any staff assistance at shift change resulting in an unwitnessed fall occurring Resident is supposed to be with a staff member at shift change and is not supposed to be left alone, unwitnessed fall occurred d/t resident being left alone at shift change and resident attempted to self transfer out of her Broda chair resulting in an unwitnessed fall occurring. Surveyor noted Resident R2's CNA (Certified Nursing Assistant) Visual/Bedside Kardex Report as of 7/24/24 under the safety section includes *At shift change someone needs to be with resident. Resident not to be left alone at shift change. Resident R2's post fall report was not signed by the Nurse Manger until 8/26/24 and DON (Director of Nursing)-B did not sign this report until 9/3/24.

Resident R2's incident note dated 9/11/24 at 23:06 (11:06 p.m.) written by LPN-R documents Date, Time and Location of Fall: 9/11/24, 1910 (7:10 p.m.), [NAME] unit Bird Lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: See charted vitals. Describe the fall: Resident found by staff sitting upright on the floor next to her Broda chair. Were there any injuries? If so, describe: Bump/hematoma to left side of forehead. Date/Time/Name of Physician Update: 9/11/24, 1950 (7:50 p.m.), On call physician [Name] with [medical group]. Date/Time/Name of Family update: 9/11/24, 2111 (9:11 p.m.), [Name] POA.

Resident R2's fall on 9/11/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw Resident R2 or what was Resident R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of Resident R2's Broda chair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 525700 Department of Health & Human Services Printed: 09/09/2025 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 525700 B. Wing 02/05/2025

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

Congregational Home, Inc 13900 W Burleigh Rd Brookfield, WI 53005

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 0689 Resident R2's incident note dated 10/7/24 at 20:13 (8:13 a.m.) written by LPN (Licensed Practical Nurse)-J documents Date, Time and Location of Fall: 10/7/2024, 2000 (8:00 p.m.), [Room number]. Vitals, including POX, Blood Level of Harm - Minimal harm or Sugar and Orthostatic BP (blood pressure): 136/74 84 20 97.3 97%. Describe the fall: resident rolled from potential for actual harm bed to mat on floor then from mat to floor. Were there any injuries? If so, describe: no injuries. Date/Time/Name of Physician Update: 10/7/2024 [name of medical group]. Date/Time/Name of Family Residents Affected - Few update: 10/7/2024, 2030 (8:30 p.m.) [Name].

Resident R2's post fall report & IDT incident follow up for 10/7/24 documents an intervention of Encourage nursing staff to monitor patient more frequently and toilet in between every 2 hour rounds. Resident R2's fall care plan was not revised to include this intervention.

Resident R2's incident note dated 10/24/24 at 17:55 (5:55 p.m.) written by LPN-J documents Date, Time and Location of Fall: 10/24/24, 1700 (5:00 p.m.), west dining room. Vitals, including POX, Blood Sugar and Orthostatic BP: 100/52, 97.9, 16, 67, 97%. Describe the fall: resident slid out of Broda chair and onto Broda foot rest. Were there any injuries? If so, describe: no injury. Date/Time/Name of Physician Update: 10/24/24 [Physician name] 1715 (5:15 p.m ). Date/Time/Name of Family update: 10/24/24, [POA name], 1715 (5:15 p.m.).

Resident R2's fall on 10/24/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw Resident R2 or what was Resident R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of Resident R2's Broda chair. The post fall report and IDT incident follow up documents an intervention of provide activities for resident to do independently. Resident R2's fall care plan was not revised to include this intervention. The Nurse Manager & DON-B did not sign the post fall report until 1/12/25.

Resident R2's incident note dated 11/9/24 at 07:32 (7:32 a.m.) written by LPN-T documents Date, Time and Location of Fall: 11/9/24 @ (at) 0418 (4:18 a.m.) Canary Lounge. Vitals, including POX, Blood Sugar and Orthostatic BP: T-96.8, P-69, R-16, B/p-145/75, POX 98% RA, BG-120. Describe the fall: Unwitnessed Fall/slide out of Broda chair. Hit head on leg of table. Neuro check negative. ROM WNL. Tenderness to top of head. Were there any injuries? If so, describe: yes; 1.0 cm (centimeter) x 1.0 cm round wound to top of scalp; cleansed et Band-Aid applied. Date/Time/Name of Physician Update: 11/9/24 @ [physician name] [medical group name]. Date/Time/Name of Family update: 11/9/24 @ 0729 am POA/[name].

Resident R2's fall on 11/9/24 was not thoroughly investigated as there are no statements included in the post fall report as to who last saw Resident R2 or what was Resident R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of Resident R2's Broda chair. The IDT incident follow up documents an intervention of Resident will be monitored more frequently while awake and when in bed for safety. Resident R2's fall care plan was not revised to include this intervention.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 525700 Department of Health & Human Services Printed: 09/09/2025 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 525700 B. Wing 02/05/2025

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

Congregational Home, Inc 13900 W Burleigh Rd Brookfield, WI 53005

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 0689 Resident R2's incident note dated 11/24/24 at 04:04 (4:04 a.m.) written by RN-I documents Date, Time and Location of Fall: 11/24/24 at 04:04 (4:04 a.m.) in dining room, slid out of Broda chair. Vitals, including POX, Blood Level of Harm - Minimal harm or Sugar and Orthostatic BP: VSS 97.7-86-18 BP 156/86 lying, & 141/86 sitting. SPO2 95% RA, blood glucose potential for actual harm at 131. Describe the fall: Resident fell in dining room area, slid out of Broda chair, sitting upright on buttocks

on floor. RN [Name] down to assess, AROM (active range of motion) to all extremities WNL (within normal Residents Affected - Few limits), PERLA (pupils equal, round and reactive to light and accommodation) Neuro check negative. Client whimpering intermittently while being hoyer lifted off the floor with 3 staff. No injury noted. Anxiety with confusion. Were there any injuries? If so, describe: None. Date/Time/Name of Physician Update: Call to [Name] hospice spoke with [hospice name] representative [name], about fall without injury. He will have RN from [hospice name] return call this morning sometime. Date/Time/Name of Family update:.

Resident R2's post fall report for fall on 11/24/24 at 4:04 a.m. documents Resident R2 was being watched by [name of staff] who stepped into a room in dining room area. Resident R2's fall care plan was not revised to include the new intervention of not to be left alone in Broda chair if restless agitated follow all nurse directives. All shift to follow this directives.

Resident R2's incident note dated 11/24/24 at 12:42 (12:42 p.m.) written by Graduate RN-S documents Date, Time and Location of Fall: 11/24/24 11:52 (11:52 p.m.) Commons area. Vitals, including POX, Blood Sugar and Orthostatic BP: T 97.7, P 84, R 16, BP 137/75, O2 (oxygen) 94% RA. Describe the fall: Unwitnessed. Pt (patient) was found c (with) back against couch. Were there any injuries? If so, describe: No apparent injuries noted. ROM (range of motion) of all extremities WNL (within normal limits). Reported soreness to btx (buttocks). Date/Time/Name of Physician Update: 11/24/24 12:15 [Name] Hospice. Staff nurse contacting [medical group name]. Date/Time/Name of Family update: 11/24/24 12:23 Daughter [name].

Resident R2's fall on 11/24/24 at 11:52 p.m. was not thoroughly investigated as there are no statements included in

the post fall report as to who last saw Resident R2 or what was Resident R2 doing. The post fall report or the IDT (interdisciplinary team) incident follow up does not indicate whether prior interventions were in place including the positioning of Resident R2's Broda chair.

On 2/5/25, at 7:10 a.m., Surveyor observed Resident R2 dressed for the day in a Broda chair slightly reclined back sleeping in the lounge area with the bird aviary. At 7:18 a.m. Surveyor observed Resident R2 is now awake. At 7:28 a. m. Resident R2 continues to be sitting in a Broda chair in the lounge area. Resident R2 removed the blanket off and has moved her feet off the Broda foot rest. CMA (Certified Medication Assistant)-U approached Resident R2, covered Resident R2 with the blanket and moved her feet back onto the foot rest. At 7:35 a.m. RN-L approached Resident R2 asking if she was hot as Resident R2 had taken off one of her blankets and tucked the hoyer sling on the right side back in. Surveyor observed Resident R2 continued to be sitting in the Broda chair in the lounge with the bird aviary until 8:23 a.m. when CNA (Certified Nursing Assistant)-V wheeled Resident R2 out of the lounge area into the dining room and placed Resident R2 at a table.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 525700 Department of Health & Human Services Printed: 09/09/2025 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 525700 B. Wing 02/05/2025

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

Congregational Home, Inc 13900 W Burleigh Rd Brookfield, WI 53005

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 0689 On 2/5/25 at 9:37 a.m., Surveyor observed Resident R2 continues to be sitting in the Broda chair at a table in the dining room. At 9:38 a.m. Resident R2 is wheeled into the lounge area from the dining room. At 9:40 a.m. a Life Level of Harm - Minimal harm or Enrichment staff member asked Resident R2 if she wanted a warm blanket telling Resident R2 let me put music on and then will potential for actual harm get you a blanket. Music was placed on and then at 9:41 a.m. the Life Enrichment staff member wheeled Resident R2 out of the lounge down the hall and returned back to the lounge with a blanket on at 9:43 a.m. At 9:48 a.m. Residents Affected - Few CNA-V wheeled Resident R2 out of the lounge and into Resident R2's room. CMA-U wheeled a hoyer lift in. Surveyor observed CNA-V & CMA-U transfer Resident R2 into bed using the hoyer lift. At 9:54 a.m. CNA-V informed Resident R2 she was going to pull her pants down. Surveyor observed CNA-V provide incontinence care to Resident R2 who was incontinent of urine & bowel. After cares were provided, CNA-V and CMA-U transferred Resident R2 back into the Broda chair, CNA-V tucked the sling into the Broda chair and remade Resident R2's bed. Resident R2 was then wheeled into the lounge.

On 2/5/25, at 10:08 a.m., Surveyor asked CNA-V if she got Resident R2 up this morning. CNA-V replied Resident R2 was up when she came in. Surveyor asked CNA-V what time her shift starts. CNA-V replied 6:30 a.m. CNA-V explained to Surveyor hospice usually comes in Monday & Wednesday and they get Resident R2 washed & dressed. Surveyor asked CNA-V how often Resident R2 is to be changed. CNA-V replied every two hours, if she is fussy then know to change her as she may be wet or pooped. Surveyor asked if Resident R2 is suppose to be checked & changed every two hours and was up already when she got here why wasn't Resident R2 checked & changed earlier. CNA-V informed Surveyor she was busy and breakfast came at 8:30 or 8:45 a.m. Surveyor noted CNA-V wheeled Resident R2 into the dining room at 8:23 a.m. the approximate time Resident R2 should have been checked & changed.

On 2/5/25, at 10:38 a.m., Surveyor asked RN-L to explain their fall process. RN-L informed Surveyor a RN has to do the post fall assessment and the resident is not moved until a RN assesses the resident. Vital signs & Neuro checks are completed, the doctor, family & NHA are notified. An incident report is filled out, anyone working with the resident fills out a statement, and a picture is drawn of what they see. Surveyor inquired if the fall is discussed as a team. RN-L informed Surveyor she believes the unit manager is involved but is not sure who is involved as she is not. Surveyor asked how the CNA's are notified of changes to a resident's care plan. RN-L informed Surveyor the Kardex is updated and also stays on the 24 hour report board to be communicated through report. Surveyor asked who revises the care plans. RN-L informed Surveyor the Unit Manager and as a RN she can update the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 525700 Department of Health & Human Services Printed: 09/09/2025 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 525700 B. Wing 02/05/2025

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

Congregational Home, Inc 13900 W Burleigh Rd Brookfield, WI 53005

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 0689 On 2/5/25, at 11:14 a.m., Surveyor asked NCM (Nurse Care Manager)-K to explain their fall process. NCM-K informed Surveyor no one touches the resident until a RN assesses the resident, Neuro checks, range of Level of Harm - Minimal harm or motion, and vital signs are obtained. The physician and family are notified. An incident report is filled out by potential for actual harm the nurse assigned to the resident and this is brought to morning meeting where they go over the report as

the IDT. Surveyor asked if staff statements are obtained. NCM-K informed Surveyor they are on the incident Residents Affected - Few report. Surveyor asked if they look to see if prior interventions were in place at the time of the fall. NCM-K replied I do. Surveyor inquired who updates the care plan. NCM-K replied she does or any other manager. Surveyor informed NCM-K since 7/3/24, Resident R2 has had 14 falls. Surveyor informed NCM-K there are multiple falls where the post fall assessment and/or IDT follow up doesn't indicate when Resident R2 was last seen, what she was doing or whether prior interventions were put into place. Resident R2's care plan was not always revised to include interventions. NCM-K informed Surveyor she was not the manager during this time and its hard for her to respond. NCM-K informed Surveyor there were two different managers before her and they are no longer with the facility. NCM-K informed Surveyor she is responsible at this point and will make sure the care plans are updated. Surveyor then informed NCM-K Resident R2 has a fall intervention that she should be checked and changed every two hours and this didn't occur this morning. NCM-K informed Surveyor if she is to be checked and changed every two hours this should happen.

On 2/5/25, at 1:00 p.m., during the meeting with NHA (Nursing Home Administrator)-A and DON-B Surveyor asked how should a residents Broda chair be positioned. NHA-A replied depends and explained if they are eating upright, leaving the table or relaxing a little titled back. S

urveyor informed NHA-A & DON-B Resident R2's falls weren't thoroughly investigated as there are no staff statements as to who last saw Resident R2, what was Resident R2 doing and whether prior interventions were in place at the time of the fall. Resident R2's fall interventions were not always followed and the care plan was not always revised to include new interventions.

No additional information was provided as to why Resident R2's falls were not thoroughly investigated, with fall interventions and revisions to the fall care plan post fall review & IDT (interdisciplinary team) not implemented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 525700