Franciscan Woods

F-F610.

Findings include:

1. The facility's policies and procedures Abuse Investigation and Reporting revised 11/2023. The Policy Statement documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of resident, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the [Corporation's name] Abuse Prevention Policy.;

The Policy Interpretation And Implementation documents:

A. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator or designee will assign the investigation to an appropriate individual.

B. The Administrator or Designee will provide any supporting documents relative to the alleged incident to

the person in charge of the investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0607 C. The Administrator or designee will keep the resident and his/her representative informed of the progress of the investigation. Level of Harm - Minimal harm or potential for actual harm D. The Administrator or designee will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.: Residents Affected - Some

The Role of the Investigator documents:

A. The individual conducting the investigation will, at a minimum:

1. Review the completed documentation forms;

2. Review the resident's medical record to determine events leading up to the incident;

3. Interview the person (s) reporting the incident;

4. Interview any witnesses to the incident;

5. Interview the resident;

6. Interview the resident's attending physician as needed;

7. Interview associates members (on all shifts) who have had contact with the resident during the period of

the alleged incident;

8. Interview the resident's roommate, family members, and visitors;

9. Interview other residents to whom the accused employee provides care or services;

10. Review events leading up to the alleged incident.

B. 3. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have them sign and date it;

Reporting documents:

A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported to the Administrator or designee and to the following officials or agencies;

1. The State licensing/certification agency responsible for surveying/licensing the community;

2. Other officials in accordance with State Law; .

F. If the investigation reveals that the allegation(s) of abuse are founded, appropriate corrective actions will be taken, including but not limited to terminating the involved employee (s) and reporting the employee to applicable licensing agency and governing authorities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0607 On 3/18/25, at 3:00 PM, at the facility daily exit meeting with Nursing Home Administrator (NHA) - A and Director of Nurses (DON) - B, Surveyor requested the investigation for Resident R10's concerns with a CNA Level of Harm - Minimal harm or documented on the facility Grievance Log. potential for actual harm

On 3/20/25, at 8:00 AM, Surveyor interviewed DON-B regarding Resident R9's care concerns. Resident R9's family expressed Residents Affected - Some care concerns on 2/17/25. The concern was documented on the facility Grievance Log, however there were no details, or documentation, on what care concerns were voiced. DON-B stated Unit Manager (UM)-E has worked closely with Resident R9 and their daughter. DON-B did not have any further documentation related to the concerns.

On 3/20/25, at 9:35 AM, DON-B informed Surveyor that an email correspondence regarding Resident R10's concern

on 1/29/25, was being sent to them by corporate human resources.

On 3/20/25, at 11:23 AM, DON-B provided Surveyor with an email correspondence between corporate human resources and Unit Manager (UM)- E. Surveyor noted DON-B was also included in the email correspondence. The email, dated 1/29/25, documents Resident R10's concern and Resident R11's concern. Resident R10 and Resident R11 voiced concerns regarding CNA-V on 1/29/25.

On 3/20/25, at 9:49 AM, Surveyor interviewed NHA-A. NHA-A stated he is in the process of investigating a care concern by Resident R9 from 3/13/25. NHA-A stated he would look into information regarding Resident R9's care concerns from February. NHA-A stated he did not recall any Facility Reported Incidents (FRI) for Resident R10, or Resident R11 related to care concerns with CNA-V. NHA-A did not recall being aware of any concerns expressed by Resident R10 and Resident R11.

On 3/20/25, at 11:00 AM, Surveyor interviewed UM-E. UM-E stated nothing happened on 2/17/25, contrary to the date on the Grievance Log. UM-E stated there was a concern with a male agency CNA. UM-E did not know the date, or the CNA's name. UM-E stated Resident R9 did not want cares by a male CNA, and the male CNA assigned to care for her did not tell anyone Resident R9 needed cares. The UM-E stated DON-B was included in the email on 1/29/25 regarding Resident R10 and Resident R11's concerns with CNA-V. UM-E found out about Resident R11's care concern with CNA-V while interviewing other residents due to Resident R10's original concern with CNA-V. UM-E stated CNA-V was a Float Pool (Company owned pool of staff that float where needed.) staff and the corporate human resources would take care of it. UM-E did not have any documentation of a thorough investigation into the concerns expressed by Resident R9's family, and Resident R10 and Resident R11.

On 3/20/25, at 11:23 AM, Surveyor interviewed DON-B regarding Resident R10's and Resident R11's care concerns with CNA-V. DON-B stated they talk about resident concerns in morning meetings. DON-B has only submitted 2 FRI's in the last 9 months, the previous Administrator submitted them. DON-B stated she did not know at the time the concerns against CNA-V would be a reportable incident of alleged abuse.

On 3/20/25, at 2:33 PM, Surveyor interviewed NHA-A. Surveyor was provided with a Coaching Feedback form for CNA-W. The form documented on 2/18/25 a female resident (Resident R9) declined care from the male caregiver (CNA-W). CNA-W did not report this to anyone else. Resident R9 did not receive any care during CNA-W's 8 hour shift. CNA-W was re-educated on performance expectations. NHA-A felt the concern was related to CNA-W not telling anyone Resident R9 did not want male caregivers. NHA-A stated he did not view this as a neglect of care and services for Resident R9. Surveyor notes this neglect allegation was not thoroughly investigated or reported to the State Survey Agency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0607 The facility did not implement their policies and procedures related to protecting residents from abuse, reporting allegations to the Nursing Home Administrator and State Survey Agency or complete a thorough Level of Harm - Minimal harm or investigation into allegations of abuse. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 21855

Residents Affected - Few Based on record reviews and interviews, the facility did not ensure allegations of abuse were reported to the Administrator, and the State Survey Agency, as required. This was observed with 3 (Resident R11, Resident R10 and Resident R9) of 3 residents reviewed for alleged abuse.

*Resident R11 alleged she asked to be changed and Certified Nursing Assistant (CNA) - V stated they just started their shift and would be back, and eventually, came back. CNA-V told Resident R11 to quit looking at the clock to see how long it's been. CNA-V told Resident R11 to turn their light, and television off, and go to bed, however Resident R11 wanted

these on. CNA-V told Resident R11 just because their old doesn't mean they can't learn. Resident R11 said ouch during cares provided by CNA-V. CNA-V told Resident R11 they are not going to help them if they keep saying ouch. There is no evidence these concerns/interactions were reported to the Nursing Home Administrator and the State Survey Agency.

*Resident R10 reported a poor interaction with a CNA on 1/29/25. A facility email by corporate human resources documents: CNA-V went into Resident R10's room to change them, at midnight, and told Resident R10 not to call again. CNA-V threw Resident R10's blankets and clothing across the room then left Resident R10 in just a brief in bed and did not come back until 5:00 AM (5 hours later). There is no evidence this was reported to the Nursing Home Administrator and

the State Survey Agency.

*Surveyor investigated Resident R9's care concerns from 2/17/25 related to not wanting a male caregiver to assist them with cares. The male caregiver did not relay this information to anyone else. Resident R9 did not receive cares

during the male caregivers 8 hour shift. There is no evidence this was reported to the State Survey Agency.

The facility's policies and procedures Abuse Investigation and Reporting revised 11/2023. The Policy Statement documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of resident, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the [name of the company] Abuse Prevention Policy.;

A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported to the Administrator or designee and to the following officials or agencies;

1. The State licensing/certification agency responsible for surveying/licensing the community;

2. Other officials in accordance with State Law.

Findings include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 1.) On 3/20/25, at 11:23 AM, Director of Nursing (DON)-B provided Surveyor an email correspondence between corporate human resources and Unit Manager (UM)- E. Surveyor notes DON-B was also included Level of Harm - Minimal harm or in the email correspondence. The email, dated 1/29/25, documents Resident R11's concern regarding Certified potential for actual harm Nursing Assistant (CNA)-V. The email is the only documentation of Resident R11's care concerns. Resident R11 alleged she asked to be changed and Certified Nursing Assistant (CNA) - V stated they just started their shift and would Residents Affected - Few be back, and eventually, came back. CNA-V told Resident R11 to quit looking at the clock to see how long it's been. CNA-V told Resident R11 to turn their light, and television off, and go to bed, however Resident R11 wanted these on. CNA-V told Resident R11 just because their old doesn't mean they can't learn. Resident R11 said ouch during cares provided by CNA-V. CNA-V told Resident R11 they are not going to help them if they keep saying ouch.

On 3/20/25, at 9:49 AM, Surveyor interviewed Nursing Home Administrator (NHA)- A. NHA-A did not recall any Facility Reported Incidents (FRI) for Resident R11's care concerns with CNA-V. NHA-A did not recall being aware of any concerns with Resident R11.

On 3/20/25, at 11:00 AM, Surveyor interviewed UM-E. The UM-E stated DON-B was included in the email on 1/29/25 regarding Resident R11. UM-E became aware of Resident R11's care concern with CNA-V, through interviewing other residents while completing an investigation into Resident R10's concerns. UM-E stated CNA-V was a float pool staff and they (human resources) would take care of it. UM-E did not have any documentation of an investigation into Resident R11's care concerns or notification of NHA-A of the concern.

On 3/20/25, at 11:23 AM, Surveyor interviewed the DON-B regarding Resident R11's care concerns with CNA-V. DON-B stated they talk about resident concerns in morning meetings and DON-B had only submitted 2 FRI's

in the last 9 months. The previous Administrator submitted them. DON-B stated she did not know at the time

the concerns expressed by Resident R11 against CNA-V would be a reportable incident.

Resident R11 care concerns with CNA-V were not reported to the Nursing Home Administrator, and the State Survey Agency, as required.

2.) On 3/18/25 Surveyor obtained, and reviewed, the facility Grievance Log. The Log documents the date, resident name, department assigned to address the grievance, room number, who voiced concern, and summary of concern with resolved date. The Grievance Log documents: On 1/29/25 Resident R10 reported they had a poor interaction with a CNA. Nurse Manager followed up with Resident R10 and Resident R10 felt the interaction was poor customer service. The CNA is a float pool and they will follow up. Resident R10 reported CNA-V went into Resident R10's room to change them, at midnight, and told Resident R10 not to call again. CNA-V threw Resident R10's blankets and clothing across

the room then left Resident R10 in just a brief in bed and did not come back until 5:00 AM (5 hours later).

On 3/18/25, at 3:00 PM, at the facility daily exit meeting with Nursing Home Administrator (NHA) - A and Director of Nurses (DON) - B, Surveyor requested the investigation for Resident R10's concerns.

On 3/20/25, at 11:23 AM, DON-B provided Surveyor an email correspondence between corporate human resources and Unit Manager (UM)- E. Surveyor notes DON-B was also included in the email correspondence. The email, dated 1/29/25, documents Resident R10's concerns regarding CNA-V. DON-B stated

they did not have any additional documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 9:49 AM, Surveyor interviewed NHA-A. NHA-A did not recall any Facility Reported Incidents (FRI) for Resident R10 care concerns with CNA-V. NHA-A did not recall being aware of any concerns with Resident R10. Level of Harm - Minimal harm or potential for actual harm On 3/20/25, at 11:00 AM, Surveyor interviewed UM-E. UM-E stated the DON-B was included in the email on 1/29/25 regarding Resident R10. The UM-E stated CNA-V was a float pool staff and they, (human resources) would Residents Affected - Few take care of it. UM-E did not have any documentation of an investigation of Resident R10's care concerns.

On 3/20/25, at 11:23 AM, Surveyor interviewed DON-B regarding Resident R10 care concerns with CNA-V. DON-B stated they talk about resident concerns in morning meetings. DON-B has only submitted 2 FRI's in the last 9 months. The previous Administrator submitted them. DON-B stated they did not know at the time Resident R10's concerns against CNA-V would be a reportable incident.

Resident R10's care concerns with CNA-V were not reported to the Nursing Home Administrator, and the State Survey Agency, as required.

3.) On 3/20/25, at 8:00 AM, Surveyor interviewed Director of Nursing (DON)-B regarding Resident R9's care concerns. Resident R9's family expressed care concerns on 2/17/25. Surveyor notes this was documented on the facility Grievance Log, however there was no details, or documentation, on what care concerns were voiced. DON-B stated the Unit Manager (UM)-E has worked closely with Resident R9 and their daughter. DON-B did not have any additional information.

On 3/20/25, at 9:49 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A stated they were in the process of investigating a care concern of Resident R9 from 3/13/25. NHA-A stated they would look into information regarding Resident R9's care concerns from February. NHA-A did not recall any Facility Reported Incidents (FRI) for Resident R9 prior to the current investigation.

On 3/20/25, at 11:00 AM, Surveyor interviewed Unit Manager (UM)-E. UM-E stated there was nothing that happened on 2/17/25, contrary to the date on the Grievance Log. UM-E stated there was a concern with a male agency CNA. UM-E did not know the date, or the name of the CNA at this time. UM-E stated Resident R9 did not want cares by a male CNA, and the male CNA-W, did not tell anyone that Resident R9 needed cares. So care was not provided to Resident R9 during CNA-W's shift.

On 3/20/25, at 2:33 PM, Surveyor interviewed NHA-A. Surveyor was provided with a Coaching Feedback form for CNA-W. The form documents: On 2/18/25 a female resident (Resident R9) declined care from the male caregiver (CNA-W). CNA-W did not report this to anyone else. Resident R9 did not receive any care for CNA-W's 8 hour shift. CNA-W was re-educated on performance expectations. NHA-A felt this was an issue of the CNA-W not telling anyone and did not originally identify the concern of Resident R9 not receiving care.

Surveyor notes Resident R9's care concern was not reported to the State Survey Agency as required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51014 potential for actual harm Based on interview and record review, the Facility did not thoroughly investigate allegations of abuse to Residents Affected - Some prevent further abuse, neglect, exploitation and mistreatment from occurring for 5 (Resident R5, Resident R6, Resident R11, Resident R10 and Resident R9) of 6 residents reviewed for abuse.

Resident R5's mistreatment allegation was not thoroughly investigated.

Resident R6's Power of Attorney made an allegation of abuse due to an injuries of unknown origin being discovered, no evidence of a thorough investigation can be provided.

Resident R11's abuse allegation was not thoroughly investigated

Resident R10's abuse allegation was not thoroughly investigated.

9's allegation of neglect was not thoroughly investigated.

Findings include:

The Facility Policy titled Abuse Investigation and Reporting Policy, revised 11/2023, documents, in part .

Policy Statement:

All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown sources (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigation will also be reported as defined by the Facility Abuse Prevention policy.

Role of the Investigator:

A. The individual conducting the investigation will, at minimum:

1. Review the completed documentation forms;

2. Review the resident's medical record to determine events leading up to the incident;

3. Interview the person(s) reporting the incident;

4. Interview any witnesses to the incident;

5. Interview the resident (as medically appropriate);

6. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 7. Interview associates members (on all shifts) who have had contact with the resident during the period of

the alleged incident; Level of Harm - Minimal harm or potential for actual harm 8. Interview the resident's roommate, family members, and visitors;

Residents Affected - Some 9. Interview other residents to whom the accused employee provides care or services;

10. Review event leading up to the alleged incident;

11. Review use of community camera/video footage of incident if available.

Reporting:

A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies:

1. The State licensing/certification agency responsible for surveying/licensing the community;

2. Other officials in accordance with State Law, including to Adult Protective Services where state law provides jurisdiction on long term facilities;

3. The Resident's Representative (Sponsor) of Record;

4. The residents Attending Physician;

5. And the community Medical Director.

B. All alleged violations involving abuse, neglect, exploitation, or mistreatment (including injuries of an unknown source and misappropriation of property) will be reported:

1. Abuse or Serious Bodily Harm-Immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury.

2. No Serious Bodily Injury-As soon as practical, but no later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury.

E. The Administrator or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Resident R5 admitted to the facility on [DATE REDACTED] with diagnoses to include acute cystitis with hematuria, vesicointestinal fistula, malignant neoplasm of bladder, and type 2 diabetes mellitus.

Resident R5's quarterly Minimum Data Set (MDS) assessment, dated 12/31/24, documents a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident R5 is cognitively intact for daily decision making.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 On 1/30/25, Resident R5 accused CNA-S of making Resident R5 wait for over an hour to be taken to the bathroom and when CNA-S assisted Resident R5 to bed that evening Resident R5's legs were slammed into the bed frame causing bruising. Resident R5 Level of Harm - Minimal harm or believed CNA-S didn't want to take care of her. potential for actual harm Surveyor reviewed the Facility Reported Incident (FRI) dated 2/10/25, which documented five resident Residents Affected - Some interviews were conducted by Licensed Practical Nurse (LPN)- Unit Manager-D on 1/31/25 when the Facility became aware of the allegation. The residents interviewed resided on the 2W (West) unit and were assigned to Certified Nursing Assistant (CNA)-S on 1/30/25 when the alleged abuse occurred. One resident stating he was given a sponge bath last time but wanted a shower. No other concerns related to the care CNA-S provided were identified.

CNA-S's work schedule on the day of alleged abuse and the following day when CNA-S, continued working, includes the following days:

1/30/25, am (day) shift, 3W (West)

1/30/25 pm (evening) shift, 2W

1/31/25 am shift, 2E (East)

On 1/30/25, day of alleged abuse, no interviews were conducted for residents on 3W when CNA-S was assigned first shift nor on 1/31/25 on 2E, the following day where CNA-S continued to work. Also, on 1/30/25,

during the PM shift, no other residents on the same unit CNA-S was assigned to and whom CNA-S could have assisted were interviewed.

On 3/18/25, at 3:20 pm, Surveyor interviewed CNA-I who states, the residents are divided by unit and assigned to a CNA. When Surveyor asked if she would help out other residents not assigned to her, CNA-I states, if she is busy, the other CNA on unit would help out. Yes, these are all of our residents, even the nurse will help out.

On 3/19/25, at 8:05 am, Surveyor interviewed LPN-P, who states even when CNA's are assigned to particular unit on the floor, they will absolutely help out the other residents on unit, including the entire floor.

On 3/18/25, at 11:45 am, Surveyor interviewed DON-B who states the process for her investigation is to

interview all staff involved, interview residents on the unit, interview resident/family of alleged incident, assess resident, potentially suspend caregiver pending investigation and potentially to call to police.

On 3/19/25 at 8:33 am, Surveyor interviewed DON-B who indicates she believes the investigation was complete and thorough. Surveyor states to DON-B that the Facility Reported Incident (FRI) had missing components. Surveyor informed DON-B of the concern, residents who were either cared for or may have been cared for by CNA-S on the same day of alleged abuse on 1/30/25 nor the residents who CNA-S cared for on the day after were interviewed. DON-B states, she understood.

On 3/19/25, at 3:05 pm, Surveyor notified both NHA-A and DON-B of the above concerns.

49011

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 2) Resident R6 was admitted to the facility on [DATE REDACTED] with diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular Level of Harm - Minimal harm or dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition potential for actual harm and encounter for palliative care.

Residents Affected - Some Resident R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating Resident R6 has severe cognitive impairment. The MDS documents Resident R6 was assessed to have no behaviors exhibited during the look back period. Resident R6 is always incontinent of bowel and bladder, no pressure injury was present, but that Resident R6 is at risk of developing pressure injuries. Resident R6 has an activated Power of Attorney (POA).

Resident R6's Significant Change MDS with an assessment reference date of 2/6/2025 does not document a BIMS assessment. The MDS documents Resident R6 was assessed to have no behaviors exhibited during the look back period. Resident R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, Resident R6 was coded to have a mechanically altered diet. Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months was coded as yes, not on a physician prescribed weigh loss regimen. The MDS documents that no pressure injury was present, but that Resident R6 is at risk of developing pressure injuries.

Surveyor reviewed the Facility Reported Incident dated 2/18/2025 that documents Resident R6's daughter voicing concerns that Resident R6 was being abused by someone. She stated that Resident R6 has bruised wrists, three skin tears and

a UTI (urinary tract infection). She stated that she has found Resident R6 tossed into bed like a rag doll with feet butt up against the footboard or bed and another time found Resident R6 in bed with wet sheets and the room temperature lowered. She further stated she found the air mattress unplugged twice.

Surveyor reviewed the Facility investigation documentation provided which included 11 staff interviews and 4 of like residents. None of the staff reported seeing any bruises or skin tears on Resident R6. None of the residents reported any abuse concerns. Surveyor requested the police report involving Resident R6's daughter's allegation of abuse from the police department and reviewed it. The police report documented that daughter reported Resident R6 is possibly being abused by nursing staff due to bruising her wrist within the last 3 weeks. I was unable to speak with Resident R6. Social Worker advised, all incidents are being investigated and have been reported to the state. No elder abuse was suspected.

Surveyor noted that 5 dates were used by the Facility to sample nurses and Certified Nursing Assistants (CNAs) who worked with Resident R6 leading up to the discovery of the injures. Surveyor notes on those 5 dates, 2 nurses and 5 CNAs that worked with Resident R6 were not interviewed as part of the investigation.

Resident R6's Pressure Ulcers/Skin Prevention care plan documents the following pertinent interventions:

-Air mattress with bolsters, check for proper functioning Q (per) shift. Start 4/6/2022

-Tubigrips on from hand to elbow in early am and off at bedtime. Hole cut for thumb. Start 8/9/2023

On 3/18/25, at 10:36 am, Surveyor observed Resident R6 in bed sleeping. The air mattress was plugged in and functioning. Resident R6's left hand was visible and a tubigrip was on with the thumb hole cut out and thumb protruding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 On 3/18/25, at 10:42 am, Surveyor interviewed Licensed Practical Nurse (LPN)-H who stated Resident R6 wears the tubigrips on their arms due to thin skin, they protect the skin. Level of Harm - Minimal harm or potential for actual harm On 3/18/25, at 1:50 pm, Surveyor interviewed LPN-H again regarding the allegations of skin tears and bruises suffered by Resident R6. LPN-H stated Resident R6 has fragile skin. Resident R6 likes to contract arms up to body and push the Residents Affected - Some tubigrips up and down arms. LPN-H stated this could be how Resident R6's skin was injured leading to the allegation of abuse involving Resident R6.

On 3/18/25, at 3:20 pm, Surveyor interviewed LPN-X about Resident R6's wrists and was told Resident R6 has always had bruising and skin tears on and off that is why the tubigrips were started. Resident R6 takes them off and staff put back on. Resident R6 crosses her arms and hands are at opposite wrist, her skin is frail and LPN-X feels Resident R6 can squeeze wrists in this position.

On 3/19/25, at 11:02 am, Director of Nursing (DON)-B provided Surveyor documentation titled Safety Event Manager that related to the investigation of this incident. Surveyor reviewed the Safety Event Manager documentation. The document stated the first skin integrity issue that occurred was reported 2/18/25 and is listed as a skin tear/discoloration. The description states contacted by unit manager regarding an email received by family. Discoloration noted to right hand and forearm, skin tear to distal aspect of right wrist, skin tear between thumb and right index finger, and skin tear/scab and discoloration to dorsal aspect of left hand. Arm protectors in place. Resident seen by wound care nurse and social work. Resident unaware of skin changes. Surveyor notes the closure date is listed as 2/19/25, and lists the closure reason as: closed with increased monitoring of similar occurrences. In the additional details section, it lists: no deviation from generally accepted performance standards, there were no preventable known complications, event was not preventable, event was not a safety event. Surveyor noted no additional documentation of the investigation was included within the document.

The second skin integrity that is documented occurred on 2/19/25 and was reported 2/20/25. It listed the event type as skin integrity and nature is pressure injury. The description is upon skin assessment a darkened area measuring 1.0 cm (centimeters) x 2.0 cm was noted on residents right heel. On call supervisor updated. [Medical group updated. Skin prep applied. Prevalon boot applied. The closure date is listed as 2/25/25, with the closure reason listed as: closed with increased monitoring of similar occurrences. Surveyor noted no additional documentation of the investigation was included within the document.

Surveyor noted the Safety Event Manager documents and the staff and residents' interviews are the only investigation documentation provided. Surveyor noted a root cause was not determined during the investigation to help identify interventions that would prevent further injury or abuse allegations from occurring. Surveyor noted no evidence of monitoring of similar occurrences was provided as stated in the Safety Event Manager documents.

On 3/19/25, at 12:23 pm, Surveyor interviewed RN (Registered Nurse) Unit Manager-C regarding the bruises and skin tears on Resident R6's wrists that were alleged as potential abuse on 2/18/25. Surveyor requested documentation of the investigation. RN Unit Manager-C stated they interviewed the CNAs and nurses that had contact with Resident R6. The root cause of the skin tears was determined to be a blood draw, and the rest was chalked up to fragile skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 Surveyor noted no documentation of the root cause of Resident R6's skin tears was provided and no interventions were put into place to prevent injury or abuse allegations from occurring. Level of Harm - Minimal harm or potential for actual harm On 3/19/25, at 3:05 pm, during the daily exit meeting with DON-B and Nursing Home Administrator (NHA)-A, Surveyor informed them of the concern related to the lack of a thorough investigation regarding Resident R6's abuse Residents Affected - Some allegation on 2/18/25. Surveyor informed DON-B and NHA-A of the concern there is no root cause for the skin injuries or identification of interventions to prevent further injury or abuse allegations from occurring. Surveyor informed NHA-A and DON-B that not all staff were interviewed that worked with Resident R6 on the sampled dates of 1/26/25, 2/6/25, 2/9/25, 2/13/25 and 2/16/25 to identify if they had additional information to add to

the investigation.

No additional information was provided as to why the Facility did not thoroughly investigate Resident R6's POA's allegation of abuse on 2/18/25.

21855

3.) Surveyor reviewed a facility email which documented Resident R11's concern with the care provided by Certified Nursing Assistant (CNA)-V. The email documented Resident R11 asked to be changed and CNA-V stated they just started their shift and would be back, and eventually came back. CNA-V told Resident R11 to quit looking at the clock to see how long it's been. CNA-V told Resident R11 to turn their light and television off, and go to bed, however Resident R11 wanted these on. CNA-V told Resident R11 just because their old doesn't mean they can't learn. Resident R11 said ouch during cares by CNA-V. CNA-V told Resident R11 they are not going to help them if they keep saying ouch.

On 3/20/25, at 11:23 AM, Director of Nursing (DON)-B provided Surveyor an email correspondence between corporate human resources and Unit Manager (UM)- E. DON-B was also included in the email correspondence. The email, dated 1/29/25, documents Resident R11's concerns regarding CNA-V. The email is the only documentation of Resident R11's care concerns related to CNA-V. DON-B stated they did not have any additional information.

On 3/20/25, at 9:49 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A stated they did not recall any Facility Reported Incidents (FRI) related to Resident R11's concerns with the care provided by CNA-V. NHA-A stated they did not recall being aware of any concerns expressed by Resident R11.

On 3/20/25, at 11:00 AM, Surveyor interviewed UM-E. UM-E stated DON-B was included in the email on 1/29/25 regarding Resident R11. UM-E stated they found out about Resident R11's care concern with CNA-V, through interviewing other residents related to Resident R10's original concern. The UM-E stated CNA-V was a float pool staff (pool of staff that work for the organization but float to different buildings), and they would take care of it. UM-E stated they did not have any documentation of an investigation into Resident R11's care concerns related to CNA-V.

On 3/20/25, at 11:23 AM, Surveyor interviewed DON-B regarding Resident R11's care concerns with CNA-V. DON-B stated they talk about resident concerns in the morning meeting. DON-B stated they only submitted 2 FRI's

in the last 9 months. DON-B stated the previous Administrator submitted them. DON-B stated they did not know at the time that Resident R11's concerns against CNA-V would be considered a reportable incident. Surveyor notes the Facility did not complete a thorough investigation into Resident R11's concerns about the care provided by CNA-V

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 4.) On 3/18/25 Surveyor obtained and reviewed the Facility Grievance Log. The log documents the date, resident name, department assigned to address the grievance, room number, who voiced concern and Level of Harm - Minimal harm or summary of concern with resolved date. The log documents: On 1/29/25, Resident R10 reported they had a poor potential for actual harm interaction with a CNA (Certified Nursing Assistant). Nurse Manager followed up with Resident R10 and Resident R10 felt the interaction was poor customer service. The CNA is a float pool staff person (pool of staff that work for the Residents Affected - Some organization but float to different buildings), and the Nurse Manager will follow up.

On 3/18/25, at 3:00 PM, at the facility exit meeting with Nursing Home Administrator (NHA) - A and Director of Nurses (DON) - B, Surveyor requested the investigation completed related to Resident R10's concerns.

On 3/20/25, at 11:23 AM, DON-B provided Surveyor with an email correspondence between corporate human resources and Unit Manager (UM)- E. DON-B was also included in the email correspondence. The email, dated 1/29/25, documents Resident R10's concern about CNA-V. The email documents CNA-V went into Resident R10's room to change them at midnight, and told Resident R10 not to call again. CNA-V threw Resident R10's blankets and clothing across the room. Then left Resident R10 in just a brief in bed and did not come back until 5:00 AM (5 hours later).

On 3/20/25, at 9:49 AM, Surveyor interviewed NHA-A. NHA-A stated they did not recall any Facility Reported Incidents (FRI) related to Resident R10's care concerns with CNA-V. NHA-A did not recall being aware of any concerns with Resident R10.

On 3/20/25, at 11:00 AM, Surveyor interviewed UM-E. UM-E stated DON-B was included in the email on 1/29/25 regarding Resident R10. UM-E stated CNA-V was a float pool staff, and they, would take care of it. UM-E did not have any further documentation of investigation into Resident R10's care concerns.

On 3/20/25, at 11:23 AM, Surveyor interviewed DON-B regarding Resident R10's care concerns with CNA-V. DON-B stated they talk about resident concerns in the morning meetings. DON-B stated they had only submitted 2 FRI's in the last 9 months. The previous Administrator submitted them. DON-B stated she did not know at

the time the concerns against CNA-V, would be considered a reportable incident. Surveyor notes the Facility did not complete a thorough investigation into Resident R10's care concerns with CNA-V.

5.) On 3/20/25, at 8:00 AM, Surveyor interviewed Director of Nursing (DON)-B regarding Resident R9's care concerns. DON-B stated Resident R9's family expressed care concerns on 2/17/25. Surveyor noted this was documented on the Facility's Grievance Log, however there were no details or documentation as to what care concerns were voiced. DON-B stated Unit Manager (UM)-E has worked closely with Resident R9 and their daughter and DON-B did not have any additional information.

On 3/20/25, at 9:49 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A stated he is in

the process of investigating a care concern by Resident R9 from 3/13/25. NHA-A stated he would look into information regarding Resident R9's care concerns from February.

On 3/20/25, at 11:00 AM, Surveyor interviewed UM-E. UM-E stated nothing happened on 2/17/25, contrary to the date on the Grievance Log. UM-E stated she was aware there was a concern with a male agency CNA and Resident R9. UM-E did not know the date she became aware of the concern or the CNA's name. UM-E stated Resident R9 did not want cares provided by a male CNA, and the CNA did not tell anyone Resident R9 needed care assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 On 3/20/25, at 2:33 PM, Surveyor interviewed NHA-A. Surveyor was provided with a Coaching Feedback form for CNA-W. The form documents: on 2/18/25 a female resident (Resident R9) declined care from the male Level of Harm - Minimal harm or caregiver CNA-W. CNA-W did not report this concern to anyone else. Resident R9 did not receive any care for the 8 potential for actual harm hour shift CNA-W worked. NHA-A stated CNA-W was re-educated on performance expectations. CNA-W signed and acknowledgement of this on 2/25/25. NHA-A felt the concern was CNA-W not telling anyone of Residents Affected - Some Resident R9's concerns and not Resident R9 receiving cares. Surveyor notes the Facility did not conduct a thorough investigation of Resident R9's concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011

Residents Affected - Few Uncorrected on Revisit

Based on observation, interview, and record review, the Facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (Resident R6, Resident R7, Resident R8) of 3 residents reviewed for pressure injuries.

*Resident R6 developed a deep tissue injury (DTI) which was discovered on 2/19/25 by a Licensed Practical Nurse (LPN). There is no documentation that the DTI was evaluated by a Registered Nurse until the Wound Nurse Practitioner saw it on 2/27/25. Additionally, Resident R6 did not have nutritional interventions attempted and Resident R6's care plan was delayed in being updated. The DTI declined to a stage 3 pressure injury.

*Resident R8 developed a Stage 2 pressure injury to left buttocks on 3/10/25. The wound was not comprehensively assessed until 3/13/25. Treatment for the pressure injury was not obtained until 3/13/25 and Resident R8's care plan was not updated until 3/13/25.

*Facility staff documented Resident R7 developed a new wound to Resident R7's mid back on 3/9/25. The wound was not comprehensively assessed until 3/13/25 when the Wound Nurse Practitioner (NP)-M documented that the wound was a stage 2 pressure injury. Resident R7's care plan was not updated with new interventions until 3/13/25, 4 days after the development of the pressure injury. On 3/16/25, Resident R7's wound care was not documented as completed.

Findings include:

1.) Resident R6 was admitted to the facility on [DATE REDACTED]with pertinent diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition and encounter for palliative care.

Resident R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating that Resident R6 has severe cognitive impairment. The MDS documents that Resident R6 was assessed to have no behaviors exhibited during the look back period. Resident R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, Resident R6 was assessed to have a mechanically altered diet. The MDS assesses no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documents that no pressure injury was present, but that Resident R6 is at risk of developing pressure injuries. Resident R6 has an activated Power of Attorney (POA).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 Resident R6's Significant Change MDS with an assessment reference date of 2/6/2025 does not document a BIMS assessment. The MDS documents that Resident R6 was assessed to have no behaviors exhibited during the look Level of Harm - Actual harm back period. Resident R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, Resident R6 was assessed to have a mechanically altered diet. The MDS assesses that Weight loss of 5% or more in the last Residents Affected - Few month or loss of 10% or more in the last 6 months occurred and Resident R6 was not on a physician prescribed weight loss regimen. The MDS assesses that no pressure injury was present, but that Resident R6 is at risk of developing pressure injuries.

Resident R6 had multiple Braden Scale for Predicting Pressure Score Risk evaluations done. Braden evaluations dated 3/9/24, 8/20/24 and 1/31/25 documented that Resident R6 was assessed to have a score of 10, indicating Resident R6 is at very high risk of developing a pressure injury. Resident R6's Braden evaluation dated 11/10/24 documents Resident R6's risk of developing a pressure injury to be a moderate risk with a score of 16.

Resident R6's Pressure Ulcers/Skin Prevention care plan documents the following interventions:

Follow community skin care protocol. Start 11/10/2021

Treatments, as indicated, see physician order sheet. Start 11/10/2021

Pressure reducing mattress on bed. Start 11/10/2021

Air mattress with bolsters, check for proper functioning Q (each) shift. Start 4/6/2022

Assist with repositioning when in bed and Broda chair during rounding and cares. Start 4/6/2022

cushion to w/c (wheelchair). Start 12/27/2022

Tubi grips on from hand to elbow in early am and off at bedtime. Hole cut for thumb. Start 8/9/2023

Prevalon Boots while in bed. Start 2/21/2025

(Resident R6) has impaired skin integrity related to right lateral heel DTI (deep tissue injury) noted on 2/19/25

Goal: (Resident R6) will be free from signs and symptoms of infection and will demonstrate optimal healing

Interventions:

Provide treatment as ordered. Start 3/11/25

Follow with wound APNP (Advanced Practice Nurse Practitioner). Start 3/11/25

Per wound rounds on 3/13/25, with wound APNP, wound is now classified as a stage III (3) pressure injury. Start 3/14/25

(Resident R6) has impaired skin integrity related to right medial heel DTI noted on 3/6/25

Goal: (Resident R6) will be free from signs and symptoms of infection and will demonstrate optimal healing

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 Interventions:

Level of Harm - Actual harm Provide treatment as ordered. Start 3/11/25

Residents Affected - Few Follow with wound APNP. Start 3/11/25

Resident R6's physician order dated 1/28/25 documents severe protein calorie malnutrition: hospice to eval (evaluate) and treat.

Resident R6's physician order dated 1/30/25 documents admit to (name of) Hospice

Surveyor noted that Resident R6's DTI was found on 2/19/25 and Prevalon boots were added on 2/21/25, which was 2 days after the DTI was identified. Surveyor noted that the rest of Resident R6's care plan was updated 3/11/25 and 3/14/25. Surveyor noted that Resident R6's the right medial heel has progressed to a stage 3 pressure injury, not the right lateral heel as documented in Resident R6's care plan.

Resident R6's physician order dated 2/19/25 documents skin prep-topical every shift to be applied to right heel q (each) shift for protection and Heels to be elevated off bed with pillows-topical continuous for protection

Resident R6's progress note, written by Licensed Practical Nurse (LPN)-X dated 2/19/2025, at 3:39 pm, documents: bed bath given. A 5.2 cm (centimeter) x 4.5 cm darkened area was noted on right heel. On call RN (Registered Nurse) Supervisor aware and will assess. Heels elevated on pillows. Skin prep to be applied q shift

Resident R6's progress note, written by LPN-X dated 2/20/2025, at 2:52 pm, documents: on 2-19-25 a 1. cm x 2.0 cm, darkened area was found on resident's right heel during a bed bath and skin check. On call RN Supervisor was updated, (name of medical group) was updated, and POA (power of attorney) was updated. Skin prep ordered and a Prevalon boot to right foot. No pain to area

Surveyor noted there was a discrepancy in Resident R6's right heel measurements listed on 2/19/25 and on 2/20/25 when Resident R6's medical doctor (MD) and POA were informed.

On 2/19/25, a Skin Evaluation Form was completed for Resident R6 by LPN-X. Documentation for the heel right is length 5.2 cm, width 4.5 cm, depth 0 cm. and the treatment of skin prep q shift, to be assessed by RN

Resident R6's physician order dated 2/20/25 documents Prevalon boot-topical every shift to be worn on right foot for protection

On 2/20/25, a Skin Evaluation Form was completed for Resident R6 by wound LPN-E. Documentation for the heel right is length 1.0 cm, width 2.0 cm, depth UTD (unable to determine) cm, cause is identified as pressure, tissue type is 0 = closed/resurfaced, exudate amount is 0 = none and stage is deep tissue injury The treatment section remained the same skin prep q shift, to be assessed by RN

On 2/27/25, a Wound Care Assessment was completed by wound Nurse Practitioner (NP)-M, the right heel DTI documentation status is documented as new. Deep tissue pressure injury 0.9 x 2.5 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 Surveyor noted this is the first documented comprehensive assessment of the wound by an RN.

Level of Harm - Actual harm On 3/6/25, a Wound Care Assessment was completed by wound NP-M, the right heel DTI documentation is right lateral heel (DTI), deep tissue pressure injury 1 x 2 cm. Intact, purple, no drainage. Peri wound is dry, Residents Affected - Few intact. No sign/symptom infection. Status- stable. A second pressure injury is discovered. Documentation is right medial heel (DTI), deep tissue pressure injury 0.5 x 1 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- new.

On 3/13/25, a Wound Care Assessment was completed by wound NP-M, documentation is right lateral heel (DTI), deep tissue pressure injury 1 x 2 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- stable. Documentation for right medial heel (stage 3 pressure injury), full thickness wound measuring 1 x 1.5 cm. 100% granular tissue. Scant serosanguinous drainage. Peri wound is dry, intact. No sign/symptom infection. Status- decline.

On 3/13/25, wound LPN-E completed the Skin Evaluation Form which documented the right lateral heel size is 1.0 cm x 1.5 cm x 0.1 cm and staged as a stage 3 pressure injury. The right medial heel size is 1.0 cm x 1. 0 cm x UTD, and stage is deep tissue injury.

Surveyor noted from 3/6/25 to 3/13/25 the DTI on the right medial heel declined to stage 3 as the measurements went from 0.5 x 1 cm to 1 x 1.5 cm. Surveyor noted wound LPN-E incorrectly documented

the right lateral heel as the stage 3 pressure injury. Surveyor noted observing wound care on 3/19/25, at 8:38am, and the stage 3 pressure injury is on the right medial heel, as NP-M documented.

Surveyor noted a delay in reporting of DTI to Resident R6's physician and POA. Surveyor noted there was a delay in implementing Resident R6's Prevalon boot as it was not added until 2/20/25, one day after Resident R6's DTI was found. Additionally, Surveyor noted that there is no documentation that an RN assessed Resident R6's heel until 2/27/25, seven days after it was initially discovered, and wound NP-M noted the DTI as new.

Surveyor noted that on 3/6/25, a DTI to Resident R6's right medial heel was also discovered. At the time, Resident R6's wound documentation is changed from right heel to right lateral heel for the DTI found 2/19/25. On 3/13/25, the right medial heel DTI progressed to a stage 3 pressure injury per wound NP-M.

Resident R6's Interdisciplinary note, written by Registered Dietician (RD)-Y dated 1/29/25, documents: aware of current weight 107 pounds which reflects a significant weight loss of 10% in the past month. Intake appears to have decreased slightly but not significantly. Continues to accept 4oz ensure enlive TID between meals. Family has decided to proceed with hospice care. Will continue to monitor.

Resident R6's interdisciplinary note, written by RD-Y dated 3/18/25, documents monitoring wounds to RLE (right lower extremity) (venous ulcer-suspicious for cancerous lesion) and Right lateral heel (DTI). Both are stable. Patient admitted to hospice 1/30/25. Oral intake varies from poor to good although Resident R6 has had an overall decrease as evidence by significant 13.85% weight loss in the past 6 months. Resident R6 does receive 4 oz ensure enlive TID (three times per day) for additional calories/protein. Due to end stage diagnosis weight and wound changes unavoidable. Will continue to offer supplement and food/fluid as patient desires.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 Surveyor noted Resident R6's RD note dated 3/18/25 was written a month after Resident R6's right heel DTI was found and did not document that Resident R6's right medial heel had progressed to stage 3. Surveyor noted Resident R6 had a severe weight Level of Harm - Actual harm loss (more than 10%) over 6 months, not significant (less than 10%) as indicated in the 3/18/25 note.

Residents Affected - Few On 3/19/25, at 12:35pm, Surveyor interviewed RD-Y and asked about any intervention changes when Resident R6's weight loss was detected, as Surveyor could not locate any in Resident R6's medical record.

RD-Y informed Surveyor that Resident R6 was palliative care so RD-Y was not super aggressive in developing interventions for Resident R6. RD-Y stated that in January RD-Y saw Resident R6 and that Resident R6 gets ensure. RD-Y stated that in January Resident R6's family proceeded with hospice care. Surveyor asked if RD-Y updated Resident R6's care plan and was told if a resident is losing weight the goal stays the same, to provide nutritional needs. RD-Y removed the part in the care plan about Resident R6 not having a weight change. RD-Y stated the goal was to provide food and fluids to try to prevent further weight loss, this is for comfort. Surveyor asked about improving Resident R6's nutrition and was told RD-Y did not implement further interventions because hospice was being discussed with the family. RD-Y saw a gradual decrease in Resident R6's appetite, comfort was the goal.

Surveyor noted Resident R6 had no interventions that were attempted which could improve protein intake. Surveyor noted Resident R6 had been on hospice previously from 9/30/21 to 9/14/22, 2 years ago.

On 3/19/25, at 1:23pm, Surveyor interviewed Hospice RN-AA about weight loss and pressure injuries. Surveyor asked Hospice RN-AA about Resident R6's pressure injury and who monitors it. Hospice RN-AA stated the facility cares for it and that pressure injuries are fairly common at the end of life, especially with Resident R6's diagnosis due to the lack of protein. Surveyor asked if Resident R6 needs a protein supplement or other interventions and was told not necessarily as pressure injuries are part of the decline.

On 3/18/25, at 2:20pm, Surveyor interviewed wound LPN-E and was told the wound NP-M stages the wounds, LPN-E just puts in what NP-M says. If a skin issue is found and it is not by the wound rounding day with NP-M, LPN-E grabs a RN to stage and documents what they say. Surveyor asked if anyone was monitoring the right heel between 2/27/25 and 3/6/25 when the new DTI was discovered by wound NP-M. LPN-E stated yes, at the weekly bath skin check and when the skin prep was applied q shift. Surveyor asked if hospice followed the wound and was told no, they are aware and are given updates weekly, but they refer to the wound NP-M for treatments. Surveyor asked why there was no RN assessment on the 19th when the DTI was found and was told there were no managers here at that point, LPN-E believes they have 24 hours for RN to put eyes on it.

On 3/18/25, at 3:20pm, Surveyor interviewed LPN-X, who found Resident R6's right heel DTI. LPN-X informed Surveyor that Resident R6's DTI was discovered during Resident R6's skin check, 2/19/25, on bath day. LPN-X let the unit manager know over the phone and was told the wound team would look at it the next day. The wound was not open when it was found.

On 3/19/25, at 10:25am, Surveyor interviewed wound LPN-E again after reviewing wound NP-M notes. Surveyor asked why the wound was found on 2/19/25, charted on by LPN-E on 2/20/25, and assessed by NP-M on 2/27/25 as new. LPN-E will look into the documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 On 3/19/25, at 12:13pm, LPN-E got back to Surveyor that since wound NP-M was coming on the 20th, LPN-E printed wound rounds on the 19th before the DTI was found, so it was not on the sheet. After NP-M Level of Harm - Actual harm left, LPN-E remembered the DTI so took RN Unit Manager-C with to assess. Surveyor asked for documentation of the RN assessing the wound and was told it is noted in treatment section. Surveyor noted Residents Affected - Few it reads to be assessed by RN in the treatment section. Surveyor asked about interventions to keep heels off bed before the DTI was discovered and LPN-E will look into. Surveyor noted no documentation was provided.

On 3/19/25, at 12:47pm, Surveyor interviewed RN Unit Manager-C and was told they had been called the night before (2/19/25) about the new wound and took care of the assessment the next day. Surveyor noted no documentation was provided of the RN assessment.

On 3/20/25, at 8:08am, Surveyor interviewed wound NP-M who stated the 2nd pressure injury developed because Resident R6 always kicks boots off. Surveyor asked about interventions in place before the DTI was discovered and NP-M cannot speak to that.

Surveyor reviewed the CNA Worksheet provided by Facility and Resident R6 is a 2 person assist for transfers, bed mobility, dressing and bathing. It is not documented on the worksheet for Resident R6 to be turned or repositioned on any schedule, float heels or wear Prevalon boots.

On 3/20/25, at 10:18am, Surveyor interviewed Resident R6's POA and asked if they had been notified of Resident R6's weight loss. Resident R6's POA responded that Resident R6's weight loss had been mentioned casually. Resident R6's POA stated they bring food in for Resident R6 and Resident R6 has no trouble eating the food. POA felt Resident R6 gets lots of skin tears and feels the bad nutrition would affect skin integrity.

On 3/20/25, at 2:06pm, Surveyor spoke with Director of Nursing (DON)-B about the concerns for Resident R6 regarding the lack of RN assessment, lack of care plan interventions or nutrition supplementation that led to

a DTI progressing to a stage 3 pressure injury.

No further information was provided at the time of write up regarding no documentation that the DTI was evaluated by a Registered Nurse (RN) until the Wound Nurse Practitioner (NP) saw it on 2/27/25, Resident R6 did not have nutritional interventions attempted and Resident R6's care plan was delayed in being updated.

Cross-reference

F-F692.

48391

2.) Resident R8 is a [AGE] year-old resident who was admitted to the facility on [DATE REDACTED]. Resident R8's diagnoses include osteoarthritis, polyneuropathy, basal cell carcinoma, stage 2 left buttocks pressure injury.

Resident R8's Quarterly Minimum Data Set (MDS) completed on 2/1/25 documents that Resident R8 is a partial/moderate assist with toileting, showering, dressing, and transferring. Resident R8 is occasionally incontinent of urine and always incontinent of bowels. Resident R8 has one stage 2 unhealed pressure injury. Resident R8 is documented as having a Brief

Interview for Mental Status (BIMS) score of 13, indicating Resident R8 is cognitively intact.

Resident R8's Care Area Assessment (CAA) for Pressure Ulcer/Injury dated 11/14/24, documents Resident R8 was admitted on [DATE REDACTED]. Resident R8 was admitted to (name of) Hospital on 10/30/24 for weakness and falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 Resident R8 has a past medical history for anxiety, depression, chronic pain, Chronic Obstructive Pulmonary Disorder (COPD), Gastroesophageal Reflux Disease (GERD), Hypertension (HTN), and shingles pain. Level of Harm - Actual harm Resident R8 reports over the past few months she has had an increased number of falls. Resident R8 has lived at an Assisted Residents Affected - Few Living Facility (ALF) for the past 3 years. Resident R8 is independent living until 3 weeks ago when she was moved to assisted living. Resident R8 is having issues with falls and needed more help with medications and Activities of Daily Living (ADL)s. Resident R8 has the following impairments: transfers, gait, balance, Range of Motion (ROM), strength, endurance/activity tolerance, safety awareness/judgment, fall risk, and pain in low back. Benefits for Resident R8 at rehab will be additional physical therapy to address deficits.

Resident R8's care plan, dated 11/4/24, documents:

Resident R8 is at risk for pressure ulcers and other skin related injuries (dated 11/4/24).

Interventions include:

Braden Scale to be completed (dated 11/4/24).

Keep bed linens wrinkle free and do not use excess pads (dated 11/4/24).

Observe skin for redness and breakdown during routine care (dated 11/4/24).

Use pressure relieving devices, cushion on wheelchair and off of heels, as indicated (dated 11/4/24).

Follow community skin care protocol (dated 11/4/24).

Treatments, as indicated, see physician order sheet (dated 11/4/24).

Pressure reducing mattress on bed (dated 11/4/24).

Resident R8 has impaired skin integrity related to cancerous hyperpigmentation on old site from biopsy, present on admission (dated 11/11/24)

Interventions include:

Follows with wound Advanced Practice Nurse Practitioner (APNP) for monitoring (dated 11/11/24).

Resident R8 has stage 2 pressure ulcer buttock (dated 2/4/25)

Interventions include:

See Electronic Treatment Administration Record (ETAR) (dated 2/4/25).

Follows with APNP for monitoring (dated 2/4/25).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 2/20/25: left buttock pressure injury resolved: denuded fragile skin due to healed pressure area (dated 3/13/25). Level of Harm - Actual harm 3/13/25: left buttock pressure injury resurfaced, now stage 2 (dated 3/13/25). Residents Affected - Few Provide treatment as ordered (dated 3/13/25).

Assist with repositioning during rounding and cares (dated 3/13/25).

Surveyor reviewed Resident R8's medical recorder which documents the following:

*Order placed on 11/6/24 to apply z-guard to coccyx every shift.

*Resident R8 received a bath on 3/10/25. Certified Nursing Assistant (CNA)- T performed the bath on Resident R8 and documents Resident R8 having a new reopened pressure wound to the left buttocks.

*Resident R8's Skin Evaluation form dated 3/12/25 documents, denuded fragile skin due to healed pressure area to

the left buttocks. Treatment includes z-guard to coccyx every shift.

*Resident R8's Skin Evaluation form dated 3/13/25 documents, left buttocks denuded fragile skin due to healed pressure area. Treatment includes z-guard to coccyx every shift.

*Resident R8's Skin Evaluation form dated 3/13/25 documents, Stage 2 full thickness wound pressure injury to left buttocks. Resurfaced 100% smooth, red, granulation, serosanguineous drainage, and moderate exudate present. Cause is pressure. Treatment changed to cleanse with Normal Saline (NS), pat dry, followed by Foam Border Dressing (FBD) to be changed daily and as needed (PRN). Surveyor notes this was the second Skin Evaluation performed for Resident R8 on 3/13/25 which was performed by Licensed Practical Nurse (LPN) Unit Manager/Wound Nurse- E who rounds with the wound care Nurse Practitioner (NP) on Thursdays.

On 3/18/25, at 10:19 AM, Surveyor interviewed Resident R8 who was sitting in the recliner on top of a pillow. Resident R8 states she prefers to sit on a pillow due to pressure injuries developing on her buttocks. Resident R8 states she spends most of her time in the recliner sitting on pillows and will occasionally go down to the dining room for meals in her wheelchair. Surveyor observed Resident R8's wheelchair in the corner of the room with a cushion on it.

Surveyor reviewed Resident R8's medical record which includes a progress note dated 3/12/25, at 3:16 PM, that documents: Resident R8 had a skin check completed on 3/11/25. Resident R8 had a previous skin condition that had since closed on her left buttocks and is now reopened. Measurements were placed in the skin condition. Treatment was not changed and Wound NP- M will assess and change treatment on 3/13/25.

Surveyor notes Resident R8's left buttocks wound was identified on 3/10/25 during her bath and facility is documenting

the wound was identified on 3/11/25 and documenting treatment be changed on 3/13/25 when Wound NP- M rounds, which is 3 days after Resident R8 developed a left buttocks stage 2 pressure injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 On 3/18/25, at 1:23 PM, Surveyor interviewed CNA- U who indicates Resident R8 spends all her time in the recliner. CNA- U indicates she has not seen Resident R8 use her bed and staff offer to take Resident R8 to the dining room for meals Level of Harm - Actual harm and sometimes Resident R8 will go but most of her meals are in her room while sitting in the recliner. Resident R8 does not attend facility activities. CNA- U states Resident R8 is continent and will press her call light for assistance to go to the Residents Affected - Few restroom.

On 3/18/25, at 1:28 PM, Surveyor interviewed Registered Nurse (RN)- K who states she will complete a comprehensive assessment, notify the unit manager, family, and Medical Director (MD) if she is told by a CNA of a new wound or discovers a new wound on a resident during an assessment. RN- K states she is a Registered Nurse and can perform comprehensive assessments and many nurses on the floor are LPNs who are not able to perform comprehensive assessments. RN- K then stated she doesn't work at the facility very often and relies on the facility CNAs for skin checks and assessments since RN- K does not see resident's skin on a regular basis. RN- K indicates the facility offered Resident R8 a cushion to use for her recliner and Resident R8 declined, indicating Resident R8 prefers to sit on pillows.

On 3/18/25, at 1:49 PM, Surveyor interviewed CNA- T who found Resident R8's new pressure injury on 3/10/25,

during Resident R8's bath. CNA- T states she notified the nurse on 3/10/25, after identifying a new pressure injury on Resident R8. CNA- T does not recall who that nurse was and then states she always updates the nurse with any new skin finding during cares.

On 3/18/25, at 1:49 PM, Surveyor interviewed LPN- P who states she will fill out the facility Skin Injury and Pressure Injury packet if a CNA notifies her of a resident having a new pressure injury. LPN- P states the Skin Injury and Pressure Injury packet has a checklist for nursing staff to complete and fill out. This check list is then placed in the gold basket in the nursing station for the unit manager to pick up and review. LPN- P states the unit managers round daily to pick up the Skin Injury and Pressure Injury packets. LPN- P states measurements and wound descriptions are completed and included in the Skin Injury packets. LPN- P also states measurements and wound descriptions should be obtained immediately and called in to the MD with updates and possible orders.

On 3/18/25, at 2:01 PM, Surveyor interviewed LPN Unit Manager- D who states floor nursing staff will notify

the unit manager, update family, and contact the MD with any new wounds or pressure injuries. LPN Unit Manager- D then stated Wound NP- M will then evaluate the resident on Thursdays during wound care rounds. LPN Unit Manager- D states the Skin Injury and Pressure Injury packet are completed by nursing staff when a new pressure injury is identified. LPN Unit Manager- D states if the floor nurse is an LPN, the LPN will get the unit manager or an RN to complete a comprehensive assessment to obtain measurements, depth, staging, and wound bed description. LPN Unit Manager- D acknowledged she will get the 1st floor unit manager who is an RN or the DON to complete a comprehensive assessment if she is contacted by nursing staff with a new pressure injury. LPN Unit Manager- D states the comprehensive assessment is completed

on the day the pressure injury is identified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 On 3/19/25, at 9:32 AM, Surveyor interviewed LPN Unit Manager- D who states the nurse will complete a comprehensive skin assessment to include measurements, depth, surrounding tissue and if there is any Level of Harm - Actual harm drainage, if a new pressure injury is identified. LPN Unit Manager- D then states the facility staff aim to complete the comprehensive assessment right away, but the facility has 24 hours to complete a full Residents Affected - Few comprehensive assessment. LPN Unit Manager- D states Wound NP- M sees every resident in the facility with a pressure injury. Surveyor notified LPN Unit Manager- D of concerns with Resident R8 having a pressure injury identified on 3/10/25 during her bath and the first comprehensive assessment completed in Resident R8's medical

record is documented on 3/13/25. Surveyor notified LPN Unit Manager- D Resident R8 did not receive treatment orders until 3/13/25. LPN Unit Manager- D states she will investigate these concerns.

On 3/19/25, at 9:56 AM, Surveyor reviewed Resident R8's medical record and notes wound care was not performed

on 3/15/25 and Resident R8 declined wound care treatment on 3/16/25. Surveyor notes Resident R8 went two days without receiving wound care treatment.

On 3/19/25, at 10:24 AM, Surveyor interviewed LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E who state the facility performed a skin sweep on 3/12/25 and Resident R8 was identified as having a new pressure injury to her left buttocks. Surveyor asked LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E if

they were aware of Resident R8 having documentation of a new pressure injury on her left buttocks on 3/10/25. LPN Unit Manager/Wound Nurse- E asked who documented the new wound on 3/10/25. Surveyor notified LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E of Resident R8 having documentation of a new pressure injury on 3/10/25 during her bath. LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E then notified Surveyor that Resident R8 had changed her bath day from Monday PMs to Wednesday AMs due to Resident R8 wanting AM baths. LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E then states Resident R8's wound was identified on 3/12/25 during the facility skin sweep. Surveyor notified LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E of concerns with Resident R8 having a new pressure injury documented on 3/10/25 and no comprehensive skin assessment, wound care orders, care plan updates, or wound care provider notification until 3/13/25. LPN Unit Manager- D states the facility had orders already going for z-guard. LPN Unit Manager/Wound Nurse- E states FBD dressings were requested by Resident R8 for additional padding.

On 3/19/25, at 10:42 AM, LPN Unit Manager- D notified Surveyor skin checks with measurements were performed on 3/11/25 for Resident R8 and is unsure why it is not documented in Resident R8's medical record.

On 3/19/25, at 1:06 PM, Surveyor interviewed Director of Nursing (DON)- B. Surveyor asked when an assessment of a new wound should take place. DON-B stated it should be assessed when found and reported to the Medical Director (MD) and Power of Attorney (POA). Treatment orders should be obtained. DON-B stated the facility wound nurse should be updated so the resident can be added to wound rounds which occur every Thursday. DON-B stated the nurse who finds the wound should complete a skin packet and incident report. Surveyor asked what should be included in the initial wound assessment. DON-B stated

it should include the location, drainage, color of the wound, and measurement. DON-B stated that this information is documented in the skin packet and in the electronic medical record. Surveyor asked about the facility wide skin sweep. DON-B stated that the sweep was completed on 3/11/25. DON-B stated that it is a different electronic program than the facility's electronic health record. Surveyor asked if staff nurses would be able to see what is documented on the skin sweep. DON-B indicated that staff nurses would not be able to see the information from the skin sweep. Staff nurses need to use the facility's electronic medical record to view any documentation on residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0686 On 3/20/25, at 7:38 AM, Surveyor observed Resident R8's wound care with LPN Unit Manager/Wound Nurse- E and Wound NP- M, Surveyor observed a Stage 2 pressure injury to the left buttocks approximately the size of a Level of Harm - Actual harm dime. No drainage was observed, wound bed was red and smooth and surrounding skin was observed to be dry and intact. Surveyor observed white cream on Resident R8's buttocks and surrounding skin. Surveyor observed Residents Affected - Few Wound NP- M notify LPN Unit Manager/Wound Nurse- E of Resident R8's left buttocks pressure injury measuring 0.6 x 0.6 x 0.1. Wound NP- M asked Resident R8 if she would sleep in her bed and Resident R8 declined. Following wound care, Surveyor interviewed Wound NP- M who states she has offered Resident R8 a cushion for her recliner in the past and Resident R8 declines. Wound NP- M states Resident R8 was previously using a donut shaped cushion to sit on and Wound NP- M asked Resident R8 and family not to use the donut shaped cushion due to it putting pressure on Resident R8's buttocks in certain spots. Wound NP- M has not seen the donut shaped cushion for a while and states she is unsure if Resident R8's son took the cushion home. Wound NP- M acknowledged Resident R8's left buttocks pressure injury measuring 0. 6 x 0.6 x 0.1 and being larger than the previous wound care rounding performed on 3/13/25 measuring 0.2 x 0.2 x 0.1. Wound NP- M states the wound looks better but is probably bigger due to noncompliance.

On 3/20/25, at 1:07 PM, Surveyor notified DON- B the following concerns for Resident R8: a new stage 2 pressure injury to her left buttocks was identified on 3/10/25 and it was not assessed comprehensively until 3/13/25 when Wound NP- M assessed the area as a stage 2 pressure injury. The skin sweep completed on 3/11/25 was not documented in Resident R8's medical record for all nursing staff to view. Resident R8's care plan was not updated until 3/13/25 which was three days after the wound was found. Resident R8's wound treatment was not completed on 3/15/25, and Resident R8 declined wound care treatment on 3/16/25. Surveyor notes to DON- B that Resident R8 went two days without receiving wound care treatments. DON- B acknowledge these concerns and states that she is familiar with the facility having 24 hours to complete a skin check for residents that are newly admitted . DON- B then stated she is not aware of what is the clock or timeframe for skin checks for newly identified pressure injuries. DON- B indicates her expectation for the nurse would be to contact the MD and complete

the skin injury packet the same day. Surveyor asked DON- B if measurements and wound bed description are included in the assessment completed the same day by the nurse. DON- B stated (name of medical group) providers ask what the wound looks like but don't always ask for measurements. DON-B states she doesn't want the [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49011

Residents Affected - Few Based on observation, interview, and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (Resident R6) of 1 resident reviewed for weight loss.

Resident R6 experienced severe weight loss over a period of 6 months, during which time Resident R6 developed pressure injuries. The weight loss was not prescribed, and no new interventions were implemented to prevent Resident R6's weight loss. Surveyor was unable to locate any documentation that the Facility updated the Power of Attorney or Resident R6's physician.

Findings include:

The facility policy and procedure titled, Nutritional Screening, Assessment, and Monitoring and last revised 11/2022, documents, in part:

Policy Statement

It is the policy of Ascension Living that a comprehensive nutritional assessment is completed upon admission, annually, or when a significant change occurs for each resident.

Policy Interpretation and Implementation

A. The RD (Registered Dietician) should complete a comprehensive nutritional assessment on each resident according to the admitted and MDS (Minimum Data Set) schedule, and clinical nutrition need.

B. A validated malnutrition screening tool will be utilized to determine malnutrition risk, as per community policy.

C. The individualized plan of care will be written and reviewed regularly when changes are noted. The plan of care will be shared with and agreed upon by the resident and/or representative.

D. A member of the food and nutrition services team will participate in the IDT (Interdisciplinary Team) care planning process and meetings according to the community's policy .

F. The dietitian will monitor regularly to ensure residents maintain acceptable parameters of nutritional status.

G. Residents are offered a therapeutic diet when it has been determined that there is a benefit .

Procedures

C. Interval assessment / Progress note will be completed for the following but are not limited to:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 1. Resident with a confirmed significant change in weight will receive a re-assessment as soon as possible but no longer than 5-days after notification, and the follow-up note will be done a minimum of weekly until Level of Harm - Actual harm weight stabilization occurs or there is a determination in the plan of care to discontinue weekly weights.

Residents Affected - Few 2. Resident with insidious weight loss (gradual unintended progressive weight loss over an extended time).

3. Residents with a new pressure injury will receive a re-assessment as soon as possible, but no longer than 5 days after notification, and the follow-up note will be done minimally monthly - until pressure injury is resolved .

The Facility Policy and Procedure titled, Procedure: Assistance with Meals and last revised 1/1/2025, documents, in part:

Purpose Statement

It is the policy of Ascension Living that residents shall receive assistance with meals in a manner that meets

the individual needs of each resident.

Policy Interpretation and Implementation

A. Dining Room Residents

1. All residents are encouraged to eat in the dining room for socialization .

4. Residents who require assistance with eating should be provided with self-help devices and/or provided help as needed.

5. Residents who are unable to feed themselves should be fed with attention to safety, comfort, and dignity .

Resident R6 was admitted to the facility on [DATE REDACTED] with pertinent diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition and encounter for palliative care.

Resident R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating that Resident R6 has severe cognitive impairment. The MDS documents that Resident R6 was assessed to have no behaviors exhibited during the look back period. Resident R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, Resident R6 was coded to have a mechanically altered diet. The MDS documents no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documents that no pressure injury was present, but that Resident R6 is at risk of developing pressure injuries. Resident R6 has an activated Power of Attorney (POA).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 Resident R6's Significant Change MDS with an assessment reference date of 2/6/2025 does not document a BIMS assessment. The MDS documents that Resident R6 was assessed to have no behaviors exhibited during the look Level of Harm - Actual harm back period. Resident R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, Resident R6 was coded to have a mechanically altered diet. The MDS documents that Weight loss of 5% or more in the last Residents Affected - Few month or loss of 10% or more in the last 6 months occurred and Resident R6 was not on a physician prescribed weight loss regimen. The MDS documents that no pressure injury was present, but that Resident R6 is at risk of developing pressure injuries.

Resident R6's care plan documents Nutritional Status, (Resident R6) is at risk for impaired nutrition related to end stage diagnosis.

Goal: (Resident R6) will have nutritional needs met.

(Resident R6) is offered diet as prescribed, see physician order sheet. Start 11/10/21

Provide supplement as ordered. Start 11/10/21

Provide assist as needed. Start 12/27/22

Surveyor noted Resident R6 had previously been on hospice from 9/30/21 to 9/14/22. Resident R6 began hospice services again on 1/30/25.

Resident R6's care plan documents Dehydration/Fluid Maintenance. (Resident R6) has a potential for fluid volume deficit related to . poor vision, may need staff assist with fluid intake use of diuretic for dx (diagnosis) of CHF (congestive heart failure).

Goal: (Resident R6) will be free from signs and symptoms of dehydration and will be well hydrated as evidenced by physical conditions.

Keep fresh water, or beverage of preference, in reach. Start 4/4/22

Assess (Resident R6's) preferred fluids and provide. Start 4/4/22

Offer 120 mL fluids with medication pass. Start 4/4/22

Staff to assist with all hot liquids and (Resident R6) to drink hot liquids while sitting at table only. Start 4/4/22

Surveyor noted Resident R6 did not have a diuretic currently prescribed.

Surveyor noted there were no updates to Resident R6's care plan when Resident R6 was taken off hospice and when Resident R6's diuretic was discontinued. Surveyor also noted that there were no new interventions when Resident R6's weight loss was discovered.

Resident R6's physician order dated 10/21/22 documents Monthly weight - due on the first Wednesday of every new month. Document refusals .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 Resident R6's physician orders dated 10/31/23 document diet: consistent carbohydrate, pureed diet . and diet: thin liquids. Level of Harm - Actual harm Resident R6's physician order dated 1/28/25 documents severe protein calorie malnutrition: hospice to eval (evaluate) Residents Affected - Few and treat.

Resident R6's physician order dated 1/30/25 documents admit to (name of) Hospice.

While investigating a Facility Reported Incident Surveyor reviewed Resident R6's electronic medical record (EMR) and found Resident R6's weights progressively declined from 7/3/2024 to the last weight taken on 1/26/25. Prior to 7/3/24, Resident R6's weight had been stable.

On 7/3/24 Resident R6's documented weight was 131.0 pounds.

On 8/7/24 Resident R6's documented weight was 124.2 pounds.

On 9/4/24 Resident R6's documented weight was 120.8 pounds.

On 10/2/24 Resident R6's documented weight was 119.4 pounds.

On 11/6/24 Resident R6's documented weight was 118.0 pounds.

On 12/10/24 Resident R6's documented weight was 119.0 pounds.

On 1/15/25 Resident R6's documented weight was 108.2 pounds.

On 1/24/25 Resident R6's documented weight was 105.9 pounds.

On 1/26/25 Resident R6's documented weight was 107.0 pounds.

Surveyor noted that there is an active physician order for monthly weights. Despite this order, Surveyor noted that 1/26/25 was the last recorded weight for Resident R6.

Surveyor noted that Resident R6 experienced a severe weight loss of 18.32% from 7/3/24 to 1/26/25 (6 months), 10. 39% from 10/2/24 to 1/26/25 (3 months), and 10.8% from 12/10/24 to 1/26/25 (1 month).

Resident R6's annual Nutrition Risk assessment dated [DATE REDACTED], completed by Registered Dietician (RD)-Y, documents under the food and nutrition history section 4 oz ensure enlive TID (three times daily). Resident R6's feeding ability is marked as extensive assistance. Surveyor noted per staff interviews (which follow) it was determined that Resident R6 is totally dependent on staff for eating and drinking, RD-Y did not mark Resident R6 as total dependence on assessment. Meal intakes (average) was marked as 51-75%. Resident R6 has chewing difficulty and no swallowing problems per assessment. Surveyor noted Resident R6 is missing many teeth per an interview with staff. At the time of the assessment the current weight was noted as 120.8 pounds (recorded in September by Facility) and

the weight trend for last 6 months was marked as stable. Comments/recommendations were Resident seen for annual review . Intake fair at meals. Mostly fed at meals. Weight 120.8 pounds, stable the past 6 months. No new interventions needed at this time. Currently free of pressure injury. Will continue to monitor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 Surveyor noted the 7/3/24 weight was 131.0 pounds, and the weight used for assessment is 120.8 which is a loss, not stable. Level of Harm - Actual harm

On 8/20/24, Resident R6 had a compliance visit with Resident R6's internal medicine doctor. The follow-up note reads monitor Residents Affected - Few behaviors, dementia, progressive decline, right lower extremity wound. Continue ongoing plan of management/care with close monitoring.

Resident R6's quarterly Nutrition Risk assessment dated [DATE REDACTED], completed by RD-Y, documents under the food and nutrition history section 4 oz ensure enlive TID remained and encourage fluids with medication pass was added. On 11/11/24 a nursing order was added to Resident R6's physician orders to encourage fluids with medication pass - 3 times per day. Provide resident with 240ml with each medication pass. Surveyor noted in an

interview with RD-Y it was indicated that this was added due to a nursing initiative. Feeding ability remained extensive assistance and meal intakes (average) were marked again as 51-75%. Chewing difficulty was indicated and no swallowing problems were noted. Resident R6's current weight is recorded as 118 pounds and the weight trend in the last 6 months was marked as stable. Comments included resident seen for quarterly

review . Intake fair at meals. Needs assistance at meals. Weight 118 pounds, stable the past 6 months. No new interventions needed at this time. Currently free of pressure injury. Will continue to monitor.

Surveyor noted that Resident R6's 7/3/24 weight was 131.0 pounds, and the weight used for assessment is 118.0 which is a loss, not stable.

Resident R6's monthly visit note from (name of NP group), written by the APRN-BC (Advanced Practice Registered Nurse-Board Certified) after a face-to-face visit on 11/20/24, documents (Resident R6) is a [AGE] year-old . being seen today for a follow-up visit. Chart and medications reviewed. Patient and staff interviewed. (Resident R6) is compliant with medication regimen. (Resident R6) is transferred by Hoyer lift and enjoys spending time sitting in Geri chair with the other residents. Weight this month is 118.0 pounds, which is down from 125 pounds in June 2024 and down from 127.2 pounds in November 2023. Staff continue to assist with meals. Discussed weight loss with nurse manager. Voicemail left for daughter/POA. Will discuss potential hospice services with POA given weight loss.

Surveyor noted that Resident R6's weight is being recorded as trending down and the information is shared with Facility staff by (name of nurse practitioner (NP) group) APRN-BC.

An email, written on 11/26/24, from Register Nurse (RN) Unit Manager-C to Resident R6's POA was provided to Surveyor. The email documents .we did have a care conference last week, (name of NP group) was present as well. I attempted to reach out and contact you during the meeting. I left a message. I'm sorry to hear you didn't receive a notice prior to the meeting .

Surveyor noted there is no mention of Resident R6's weight loss. This email was provided when Surveyor requested documentation that Resident R6's POA was updated by the Facility regarding Resident R6's weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 Resident R6's follow up visit note from (name of NP group), written by APRN-BC after a face-to-face visit with Resident R6 on 12/9/24, documents (Resident R6) is a [AGE] year old . being seen today for a follow-up visit. Chart and medications Level of Harm - Actual harm reviewed. Patient and staff interviewed. (Resident R6) is compliant with medication regimen. (Resident R6) is transferred by Hoyer lift and enjoys spending time sitting in Geri chair with the other residents. (Resident R6's) most recent weight is Residents Affected - Few 118.0 pounds, which is down from 125 pounds in June and down from 127.2 pounds in November 2023. Staff continue to assist with meals. Voicemail message left for daughter/POA to discuss potential hospice services with POA given weight loss.

Resident R6's clinical note written by the (name of NP group) APRN-BC on 12/18/24, which was communicated with POA and Registered Nurse at Facility documents .(Resident R6) most recent weight is 119.0 pounds, which is down from 125 pounds in June 2024 and down from 127.2 pounds in November 2023. Staff continue to assist with meals and Resident R6 drinks ensure. Discussed vascular dementia, weight loss/protein calorie malnutrition with daughter/POA and nurse manager. (Resident R6) has a painful lower extremity venous ulcer full thickness wound and

a chronic scab to the right side of nose. Daughter/POA notes that this area on right lower extremity has been

an area of concern by dermatologist in the past - likely a skin malignancy. POA also reports she would like comfort goal of care for (Resident R6). Plan for a hospice referral due to vascular dementia, weight loss and protein calorie malnutrition. POA is in agreement. Order given to Nurse Manager.

Resident R6's clinical note written by the (name of NP group) APRN-BC on 1/16/25, which was communicated with Nurse Manager at Facility documents Chart review completed. Met with (Resident R6) who is resting comfortably in bed. (Resident R6) states is tired and would like to sleep . Spoke with Nurse Manager and reviewed. Daughter had wanted dermatology consult for chronic wound on right shin and this was being scheduled. Called and spoke with daughter/POA. Discussed chronic wound to right shin and concern for its removal and biopsy which could possibly create an even larger wound area, and if grafting was needed would actually create 2 wounds. Also discussed weight loss, recorded weight show (Resident R6) has lost another 10 pounds in the last month, current weight 108 pounds. POA under impression that biopsy could be completed at SNF (skilled nursing facility). Discussed that was not possible and (Resident R6) would need to be sent for outpatient . POA has decided does not want dermatology referral and would like wound team at SNF to continue treating the wound as they have been. Discussed hospice referral . At the end of the conversation POA did agree to have a hospice evaluation for (Resident R6) and have hospice contact her to discuss and answer all her questions. Called and spoke with 1st Floor Nurse Manager- who will cancel dermatology referral .

(Resident R6's) progress note, written by RN Unit Manager-C dated 1/17/2025, documents Writer spoke with (name of NP group), who had followed up with family regarding dermatology consult. POA has decided that is not the route she wants to go. POA stated would prefer to move towards hospice .

Surveyor noted no documentation of the Facility discussing weight loss with POA or Resident R6's physician was located.

On 1/17/2025, Resident R6 was seen by the APNP (Advanced Practice Nurse Practitioner) for a monthly follow up appointment. The Chief Complaint section documents APNP monthly compliance visit - dementia with decline, anxiety, plans for hospice.

Surveyor noted was not able to find documentation of the weight loss being discussed with APNP in the evaluation or nursing concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 Resident R6's Interdisciplinary note, written by RD-Y, dated 1/29/25, documents aware of current weight 107 pounds which reflects a significant weight loss of 10% in the past month. Intake appears to have decreased slightly Level of Harm - Actual harm but not significantly. Continues to accept 4oz ensure enlive TID between meals. Family has decided to proceed with hospice care. Will continue to monitor. Residents Affected - Few Upon admission to hospice the hospice provider completed a Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report which has the following pertinent orders dated 1/30/25. Skilled nursing to educate patient/family on dietary modification to improve overall nutrition as tolerated including Providing small, frequent meals, offer small amounts of fluids frequently, offer but do not force food/fluids. Skilled nursing to educate caregivers on offering, but not forcing food/fluids.

Surveyor noted these hospice orders were not integrated into Resident R6's care plan.

On 3/19/25, at 1:23pm, Surveyor interviewed Hospice RN-AA about monthly weights. RN-AA stated that facilities in general do monthly weights, when on hospice, facilities can stop taking weights. Hospice can request for them to take weights though. Surveyor asked RN-AA what interventions were in place for Resident R6 weight loss. Hospice RN-AA told Surveyor weight loss is a normal part of the process with Resident R6's hospice diagnosis of unspecified severe protein calorie malnutrition with prognosis of 6 months or less if the disease runs its normal course. Per RN-AA even if Resident R6 took in more calories Resident R6 would lose weight due to the diagnosis. It is completely normal with Resident R6's diagnosis and being on hospice in general for weight loss to occur. Surveyor asked about the Interdisciplinary Group orders for skilled nursing to educate patient/family

on dietary modification to improve overall nutrition as tolerated including Providing small, frequent meals, offer small amounts of fluids frequently, offer but do not force food/fluids. Skilled nursing to educate caregivers on offering, but not forcing food/fluids. Per RN-AA skilled nursing refers to the hospice RN and

they should educate staff how to offer food and fluids. This is part of the normal decline, a resident will not eat/drink as much because it is part of the dying process. Surveyor asked if resident is actively dying and was told no declining now. Surveyor asked if small frequent meals should be an order and was told no not necessarily. Staff should offer fluids at regular intervals and feed at mealtime, RN-AA was not sure if Resident R6 gets snacks. RN-AA informed Surveyor it is fairly certain Resident R6 is not eating much as that is part of Resident R6's end of life diagnosis. Surveyor asked RN-AA about Resident R6's pressure injury and who monitors it. RN-AA stated the facility cares for it and that pressure injuries are fairly common at the end of life, especially with Resident R6's diagnosis due to the lack of protein. Surveyor asked if Resident R6 needs a protein supplement or other interventions and was told not necessarily as pressure injuries are part of the decline.

Resident R6's significant change Nutrition Risk assessment dated [DATE REDACTED], completed by RD-Y, documents under the food and nutrition history section 4 oz ensure enlive TID and encourage fluids with medication pass remained. Feeding ability remained extensive assistance and meal intakes (average) were changed to 26-50%. Chewing difficulty was indicated and no swallowing problems were noted. Resident R6's current weight was recorded as 107 pounds and the weight trend in the last 6 months was recorded as significant weight loss. Comments/Recommendations are written as (Resident R6) seen for significant change assessment . Intake fair-poor at meals. Needs assist at meals. Weight 107 pounds, weight loss of 9% times 1 month noted from December to January. Family has opted for hospice care. No new interventions needed at this time. Right shin venous/stasis wound noted. Will continue to monitor.

On 3/19/25, at 12:35pm, Surveyor interviewed RD-Y and asked about any intervention changes when Resident R6's weight loss was detected, as Surveyor could not locate any in Resident R6's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 RD-Y informed Surveyor that Resident R6 was palliative care so RD-Y was not super aggressive in developing interventions for Resident R6. RD-Y stated that in January RD-Y saw Resident R6 and that Resident R6 gets ensure. RD-Y stated that in Level of Harm - Actual harm January Resident R6's family proceeded with hospice care. Surveyor asked if RD-Y updated Resident R6's care plan and was told if a resident is losing weigh the goal stays the same, to provide nutritional needs. RD-Y removed the part Residents Affected - Few about Resident R6 not having a weight change from the care plan. RD-Y stated the goal was to provide food and fluids to try to prevent further weight loss, this is for comfort. Surveyor asked about improving Resident R6's nutrition and was told RD-Y did not implement further interventions because hospice was being discussed with the family. RD-Y saw a gradual decrease in Resident R6's appetite, comfort was the goal.

Surveyor noted Resident R6 had no interventions attempted which could provide comfort for Resident R6 and prevent further weight loss. Surveyor noted Resident R6 had been on hospice previously from 9/30/21 to 9/14/22, 2 years ago.

Resident R6's progress note written by Licensed Practical Nurse (LPN)-X dated 2/19/2025, at 3:39pm, documents bed bath given. A 5.2cm (centimeter) x 4.5cm darkened area was noted on right heel. On call RN (Register Nurse) Supervisor aware and will assess. Heels elevated on pillows. Skin prep to be applied q shift.

Resident R6's progress note, written by LPN-X dated 2/20/2025, at 2:52pm, documents on 2-19-25 a 1.0cm x 2.0cm, darkened area was found on resident's right heel during a bed bath and skin check. On call RN Supervisor was updated, (name of medical group) was updated, and POA was updated. Skin prep ordered and a Prevalon boot to right foot. No pain to area.

Surveyor noted there was a discrepancy in Resident R6's right heel measurements listed on 2/19/25 and on 2/20/25 when Resident R6's physician and POA were informed. Surveyor noted that on 3/6/25, a DTI to the right medial heel is also discovered and on 3/13/25, the right medial heel DTI progressed to a stage 3 pressure injury.

Surveyor notes no documentation of nutritional interventions are found.

Resident R6's interdisciplinary note, written by RD-Y dated 3/18/25, documents monitoring wounds to RLE (venous ulcer-suspicious for cancerous lesion) and Right lateral heel (DTI) (Deep tissue injury). Both are stable. Patient admitted to hospice 1/30/25. Oral intake varies from poor to good although (Resident R6) has had an overall decrease as evidence by significant 13.85% weight loss in the past 6 months. Resident R6 does receive 4 oz ensure enlive TID for additional calories/protein. Due to end stage diagnosis weight and wound changes unavoidable. Will continue to offer supplement and food/fluid as patient desires.

Surveyor noted Resident R6's RD note dated 3/18/25 was written a month after Resident R6's right heel DTI was found and did not document the Resident R6's right medial heel had progressed to stage 3. Surveyor noted Resident R6 had a severe weight loss (more than 10%) over 6 months, not significant (less than 10%) as indicated in the 3/18/25 note. Surveyor noted no further assessment completed related to Resident R6 oral intake decreasing, for instance determination of what food Resident R6 likes and may be more likely to consume.

Surveyor noted was unable to locate any documentation why, with only a slightly decreased intake, Resident R6 would suffer severe weight loss. Surveyor noted that Resident R6 had no new interventions identified for Resident R6's weight loss other than hospice services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 On 3/18/25, at 1:50pm, Surveyor interviewed LPN-H who confirmed Resident R6 is supposed to get monthly weights.

Level of Harm - Actual harm On 3/18/25, at 2:20pm, Surveyor interviewed wound LPN-E who stated Resident R6 has lots of issues. Regarding weight loss, Resident R6 is on hospice so decline is expected. If resident is on hospice facility staff do not do weights Residents Affected - Few unless hospice orders them.

Surveyor noted an active physician order for monthly weights dated 10/21/22.

On 3/18/24, at 3:20pm, Surveyor interviewed LPN-X regarding weight loss. LPN-X states that the unit nurse manager tracks weights. Resident R6 is on hospice, is fed by staff and accepts food but is not a big eater. Weight loss was happening before Resident R6 was on hospice. Resident R6 has very few teeth so gets a soft diet. Prefers food warm and with coffee.

Surveyor noted on 12/10/21 Resident R6's POA elected eye care from the Facility provider, dental was not selected.

On 3/19/25, at 1:54pm, Surveyor interviewed RN Unit Manager-C who stated that the RD monitors weights and then staff talk at the daily meetings about this information.

On 3/20/25, at 8:08am, Surveyor interviewed Certified Nursing Assistant (CNA)-J about how Resident R6 is set up for meals and was told Resident R6 is a total assist of puree diet. Staff feed Resident R6 every meal. Staff stop and give sips of water during the day. If Resident R6 refuses or will not finish the whole meal it is entered in the charting as the percent eaten. Resident R6 has been a total assist a long time, more than a year.

On 3/20/2025, at 9:53 am, Surveyor interviewed RN Unit Manager-C and asked for evidence the Facility informed Resident R6's POA or physician of the weight loss. Surveyor noted only (name of NP group) notes were provided that showed POA being updated by (name of NP group) APRN-BC. Surveyor asked for evidence Resident R6 was being fed all 3 meals and was told the January intake forms were provided to Surveyor, RN Unit Manager-C knows there are holes in the documentation, however, assures Surveyor that they check whenever they work that everyone is being fed appropriately. Surveyor noted while reviewing the intake forms many time slots (holes) were left blank hence not documented if a meal was attempted. In 31 days, 44 meals were not recorded and 49 were documented on. Surveyor asked what happens with the hospice plan of care report and was told staff are to read it for reference. When asked if the small meals and snacks should have been added to the care plan the response was RN Unit Manager-C felt the ensure between meals was the snack and resident could eat as much of meal as wanted.

On 3/20/25, at 10:00am, Surveyor interviewed RD-Y again. Surveyor asked why there is a difference in charting. The MDS reads Resident R6 is totally dependent, Kardex reads max assistance, meal ticket has needs assist and RD assessments show extensive assistance. Per RD-Y extensive assistance has no set definition other than the resident needs someone with them the whole time. The meal ticket with needs assist means

the resident needs to be fed. Surveyor asked why Resident R6 had a puree diet and was told the altered diet had been in place even before the current order. Per RD-Y, Resident R6 loves puree and has never complained. Surveyor asked why RD-Y referred to weight loss as significant when it is severe and was told it is the verbiage RD-Y uses, RD-Y does not use the severe category like Surveyors. Again, Surveyor clarified that no interventions were attempted in the last 6 months when weight loss occurred and was told none were added.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0692 On 3/20/25, at 10:18am, Surveyor interviewed Resident R6's POA and asked if they had been notified of Resident R6's weight loss. Resident R6's POA responded that Resident R6's weight loss had been mentioned casually. Resident R6's POA stated they bring Level of Harm - Actual harm food in for Resident R6 and Resident R6 has no trouble eating the food. POA felt Resident R6 gets lots of skin tears and feels the bad nutrition would affect skin integrity. Residents Affected - Few

On 3/20/25, between 12:40pm and 12:55pm, Surveyor observed Resident R6 being assisted to eat by LPN-H. Resident R6 stated help me multiple times during the observation, LPN-H would ask what can I help you with and Resident R6 would reply food. Resident R6 was assisted to drink coffee between bites of food.

Surveyor requested labs from the RN Unit Manager-C and was provided labs done on 2/16/25 and 2/17/25.

On 3/20/25, at 1:30pm, Surveyor asked RN Unit Manager-C for labs prior to the 2025 labs provided and was told labs had not been completed in quite a while because Resident R6 was on hospice, off hospice and back on again, labs had not been done in over a year.

On 3/20/25, at 2:45pm, Surveyor interviewed MD-Z and asked if there was a significant weight change in a resident should they be notified and was told not directly. MD-Z makes rounds at several facilities, staff should contact the on-site NP who will then contact MD-Z if there are concerns. Surveyor asked if MD-Z was aware Resident R6 had weight loss and was told MD-Z last saw Resident R6 in February and knows Resident R6 lost 10 pounds in one month. Surveyor asked if any interventions should have been started and was told the family was thinking about hospice. With Resident R6 having advanced dementia and the leg wound MD-Z would expect a decline, Resident R6 gets ensure and was eating fair to good, MD-Z felt the RD could handle.

On 3/20/25, at 2:06pm, Surveyor spoke with Director of Nursing (DON)-B regarding Resident R6's weight loss. DON-B stated they were not aware of the issue. Surveyor stated no interventions being put in place is a concern and was told during daily clinical report significant changes are brought up, nursing would not be involved with nutrition interventions. Surveyor also stated that the RD charted Resident R6's weight as stable in assessments when weight loss was occurring. Surveyor told DON-B they had requested documentation that Resident R6's POA or MD had been updated about the weight loss by the Facility and none had been provided. Surveyor also discussed the intake forms not being charted on daily so there is no evidence Resident R6 is being fed three meals a day. After the weight loss a pressure injury developed.

No further information was provided at the time of write up regarding the severe weight loss Resident R6 experienced that was not prescribed. No new interventions were implemented to prevent Resident R6's weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 21855 Residents Affected - Few Based on observation, record review and interview, the facility did not comprehensively assess a resident

before applying bed mobility devices. This was observed with 1 (Resident R9) of 1 residents observed with bed mobility devices.

* Resident R9 was observed with bilateral bed mobility devices. There was not a comprehensive assessment completed.

Findings include:

The facility's policy and procedure Device Evaluation Form dated 1/2024. The policy documents: Any resident for whom a safety or assistive is being considered will have a Device Evaluation form completed and reviewed by the interdisciplinary team.

On 3/19/25, at 12:35 AM, Surveyor observed Resident R9 in their bed. The bed had bilateral mobility devices.

Resident R9's medical record documents in the Progress Notes: on 3/13/25 (Resident R9) was readmitted from the hospital and is alert and oriented. (Resident R9's) family requested bed railings on the bed. The bed rails will be installed tomorrow by maintenance.

The Maintenance Work Order, dated 3/13/25, documents bed mobility devices were installed on Resident R9's bed.

Resident R9's Device Evaluation form, dated 3/16/25, indicates no device needed.

Resident R9 signed a consent for Use of Assistive Devices form on 3/13/25. This form is a check box style. It documents, bed rail, for assist device type.

Resident R9's comprehensive plans of care were provided. The Activity of Daily Living Functional/ Rehab Potential dated 3/19/25, under, The Bed Mobility, is 1 person staff support and uses a slide sheet. The plan of care does not document bed mobility devices.

Resident R9's physician plan of care dated 3/19/25. There is not a physician order for bed mobility devices.

On 3/20/25, at 8:00 AM, Surveyor interviewed the Director of Nurses (DON) - B. DON-B did not know why

the Device Evaluation form was checked for no. DON-B will look for more information.

On 3/20/25, at 11:00 AM, Surveyor interviewed Resident R9's Unit Manager (UM) - E. UM-E stated they can apply bed rails per family requests. The bed rails are not considered a restraint. UM-E did not have a documented comprehensive assessment for the bed mobility devices. UM-E stated Resident R9's daughter wanted them on the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0700 On 3/20/25, at 11:31 AM, DON-B spoke with Surveyor. DON-B provided a signed consent for mobility devices. DON-B did not provide documentation of a comprehensive assessment for the use of the bed Level of Harm - Minimal harm or mobility devices. potential for actual harm

On 3/20/25, at 2:30 PM,Surveyor shared the concerns with Resident R9's bed mobility devices with the Nursing Home Residents Affected - Few Administrator-A, and DON-B.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 21855 potential for actual harm Based on record review and interview, the facility did not have documentation for investigating, and Residents Affected - Many controlling, an outbreak. The facility did not document infection organisms for surveillance prevention. This had the potential to effect all 84 residents in the facility.

* The facility had an influenza A outbreak in February 2025. There is no documented investigation summary for identifying, preventing and controlling, the spread of infection.

* The facility on-going surveillance does not identify infection organisms.

Findings include:

The facility's policy and procedures Outbreak of Communicable Diseases dated 1/2024. The policy documents: The outbreaks of communicable diseases within the the community (facility) will be promptly identified and appropriately handled.

The facility's policy and procedures Infection Prevention and Control Program dated 8/2024. The policy document includes: The Infection Prevention Control Program (IPCP) is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections;

The Policy and Procedures documents:

1. a.) Prevent, detect, investigate, and control infections in the community;

1. d.) Maintain records of incidents and corrective actions related to infections;

Surveillance documents:

3. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring associate infections, and detecting unusual pathogens with infection control implications;

Facility Outbreak Management documents:

4. a.) Determining the presence of an outbreak;

4. b.) Managing the impacted residents and associates;

4. c.) Preventing the spread to other residents and associates;

4. d.) Documenting information about the outbreak;

4. e.) Reporting the information to appropriate public health authorities;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 525528 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 525528 B. Wing 03/20/2025

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

Franciscan Woods 19525 W North Ave Brookfield, WI 53045

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 0880 4. f.) Educating associates and visitors;

Level of Harm - Minimal harm or 4. g.) Monitoring for reoccurrences; potential for actual harm 4. h.) Reviewing the care after the outbreak has subsided. Residents Affected - Many Surveyor reviewed the facility's Surveillance Logs from the last 3 months, along with any infection outbreaks.

The Surveillance Logs from January 2025, February 2025 and March 2025, do not include the organism related to the infection. The February Surveillance Log includes a resident line list for influenza A. There are 14 residents from the 3rd floor on this list.

On 3/18/25, at 11:24 AM, Surveyor interviewed the Infection Preventionist (IP) - R. IP-R stated they only have a line list for the influenza A outbreak. IP-R stated they will look for any additional information.

On 3/18/25, at 2:00 PM, Surveyor interviewed IP-R. The facility Surveillance Logs were reviewed during the interview. IP-R did not have any more documentation on the influenza A outbreak. IP-R stated there was no staff that got sick. IP-R stated some residents were admitted with the influenza A. All the positive residents were in isolation. IP-R stated they did not document an investigative summary for the influenza A outbreak. IP-R did not provide a reason why they did not document it. IP-R did provide an covid outbreak investigative summary from January 2025. The facility Surveillance Logs were reviewed . IP-R does not track infection organisms unless they are a reportable organism. IP-R stated they have been only documented the MDRO's (multidrug-resistant organisms). IP-R did not provide a reason for not tracking all organisms that caused infection in the facility.

On 3/18/25, at 3:00 PM, Surveyor shared the infection control program concerns with Nursing Home Administrator (NHA) - A and Director of Nurses (DON) - B.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 525528