Alden Meadow Park Hcc

F-F688

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

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 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 38882

Residents Affected - Many Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare & Medicaid Services (CMS.) This has the potential to affect all 65 residents residing within the facility.

The facility failed to enter accurate data in their Payroll Based Journal (PBJ) reporting and triggered for four fiscal year quarters for excessively low weekend staffing, triggered one fiscal year quarter for failure to have licensed nursing coverage 24 hours a day, and triggered for one fiscal year quarter for failure to have RN (registered nurse) hours each day

Evidenced by:

According to https://www.cms. gov/medicare/quality/nursing-home-improvement/staffing-data-submissionExample the Centers for Medicare & Medicaid Services (CMS) has long identified staffing as one of the vital components of a nursing home's ability to provide quality care. CMS has utilized staffing data for a myriad of purposes in an effort to more accurately and effectively gauge its impact on quality of care in nursing homes . Therefore, CMS has developed a system for facilities to submit staffing information - Payroll Based Journal (PBJ). This system allows staffing information to be collected on a regular and more frequent basis than previously collected. It is auditable to ensure accuracy . The first mandatory reporting period began July 1,2016 . The deadlines for each reporting period are as follows: Fiscal Quarter 1-October 1- December 31 due February 14, Fiscal Quarter 2- January 1- March 31 due May 15, Fiscal Quarter 3- April 1 - June 30 due August 14, Fiscal Quarter 4- July- September 30 due November 14 . November 1, 2017, CMS began posting a public use file containing PBJ staffing data submitted by long term care facilities. The file includes the hours nursing staff are paid to work each day, for each facility. The categories of nursing staff include director of nursing, registered nurses with administrative duties, registered nurses, licensed practical nurses with administrative duties, licensed practical nurses, certified nurse aides, medication aides, and nurse aides in training. The file also includes a facility's census for each day within the quarter as calculated using the minimum data set (MDS) submission.

Example 1:

CMS's PBJ Staffing Data Report, for fiscal year quarter 1 2024 (October 1 - December 31), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . Excessively Low Weekend Staffing: Triggered - Submitted Weekend Staffing data is excessively low . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility .

Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 10/1/2024-12/31/24. (It is important to note this report would have showed the hours that were reported to CMS.)

Example 2:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

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 0851 CMS's PBJ Staffing Data Report, for fiscal year quarter 3 2024 (April 1 - June 30), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . One Star Staffing Level of Harm - Minimal harm or Rating: Triggered-Star Staffing Rating Equals 1 . Excessively Low Weekend Staffing: Triggered - Submitted potential for actual harm Weekend Staffing data is excessively low . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility . Residents Affected - Many Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 4/1/24-6/30/24. (It is important to note this report would have showed the hours that were reported to CMS.)

Example 3:

CMS's PBJ Staffing Data Report, for fiscal year quarter 2 2024 (January 1 - March 31), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . Excessively Low Weekend Staffing: Triggered - Submitted Weekend Staffing data is excessively low . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility .

Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 1/1/24-3/31/24. (It is important to note this report would have showed the hours that were reported to CMS.)

Example 4:

CMS's PBJ Staffing Data Report, for fiscal year quarter 4 2024 (July 1 - September 30), includes: This Staffing Report identifies areas of concern that will be triggered . requires follow-up during survey . One Star Staffing Rating: Triggered-Star Staffing Rating Equals 1 . Excessively Low Weekend Staffing: Triggered-Submitted Weekend Staffing data is excessively low . Failed to have Licensed Nursing Coverage 24 Hours/Day: Triggered-Four or More Days Within the Quarter with less than 24 Hours/Day Licensed Nursing Coverage. See Infraction Dates . Possible reasons for suppressed metrics: Invalid data, Facility is too new to rate, Special Focus Facility . Infraction Dates:

No RN (Registered Nurse) Hours: 07/01 (MO); 07/02 (TU); 07/03 (WE); 07/04 (TH); 07/05 (FR); 07/06 (SA); 07/07 (SU); 07/08 (MO); 07/09 (TU); 07/10 (WE); 07/11 (TH); 07/12 (FR); 07/13 (SA); 07/14 (SU); 07/15 (MO); 07/16 (TU); 07/17 (WE); 07/18 (TH); 07/19 (FR); 07/20 (SA); 07/21 (SU); 07/22 (MO); 07/23 (TU); 07/24 (WE); 07/25 (TH); 07/26 (FR); 07/27 (SA); 07/28 (SU); 07/29 (MO); 07/30 (TU); 07/31 (WE) 08/01 (TH); 08/02 (FR); 08/03 (SA); 08/04 (SU); 08/05 (MO); 08/06 (TU); 08/07 (WE); 08/08 (TH); 08/09 (FR); 08/10 (SA); 08/11 (SU); 08/12 (MO); 08/13 (TU); 08/14 (WE); 08/15 (TH); 08/16 (FR); 08/17 (SA); 08/18 (SU); 08/19 (MO); 08/20 (TU); 08/21 (WE); 08/22 (TH); 08/23 (FR); 08/24 (SA); 08/25 (SU); 08/26 (MO); 08/27 (TU); 08/28 (WE); 08/29 (TH); 08/30 (FR); 08/31 (SA) 09/01 (SU); 09/02 (MO); 09/03 (TU); 09/04 (WE); 09/05 (TH); 09/06 (FR); 09/07 (SA); 09/08 (SU); 09/09 (MO); 09/10 (TU); 09/11 (WE); 09/12 (TH); 09/13 (FR); 09/14 (SA); 09/15 (SU); 09/16 (MO); 09/17 (TU); 09/18 (WE); 09/19 (TH); 09/20 (FR); 09/21 (SA); 09/22 (SU); 09/23 (MO); 09/24 (TU); 09/25 (WE); 09/26 (TH); 09/27 (FR); 09/28 (SA); 09/29 (SU); 09/30 (MO)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

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 0851 Failed to have Licensed Nursing Coverage 24 Hours/Day: 07/01 (MO); 07/02 (TU); 07/03 (WE); 07/04 (TH); 07/05 (FR); 07/06 (SA); 07/07 (SU); 07/08 (MO); 07/09 (TU); 07/10 (WE); 07/11 (TH); 07/12 (FR); 07/13 Level of Harm - Minimal harm or (SA); 07/14 (SU); 07/15 (MO); 07/16 (TU); 07/17 (WE); 07/18 (TH); 07/19 (FR); 07/20 (SA); 07/21 (SU); potential for actual harm 07/22 (MO); 07/23 (TU); 07/24 (WE); 07/25 (TH); 07/26 (FR); 07/27 (SA); 07/28 (SU); 07/29 (MO); 07/30 (TU); 07/31 (WE) 08/01 (TH); 08/02 (FR); 08/03 (SA); 08/04 (SU); 08/05 (MO); 08/06 (TU); 08/07 (WE); Residents Affected - Many 08/08 (TH); 08/09 (FR); 08/10 (SA); 08/11 (SU); 08/12 (MO); 08/13 (TU); 08/14 (WE); 08/15 (TH); 08/16 (FR); 08/17 (SA); 08/18 (SU); 08/19 (MO); 08/20 (TU); 08/21 (WE); 08/22 (TH); 08/23 (FR); 08/24 (SA); 08/25 (SU); 08/26 (MO); 08/27 (TU); 08/28 (WE); 08/29 (TH); 08/30 (FR); 08/31 (SA) 09/01 (SU); 09/02 (MO); 09/03 (TU); 09/04 (WE); 09/05 (TH); 09/06 (FR); 09/07 (SA); 09/08 (SU); 09/09 (MO); 09/10 (TU); 09/11 (WE); 09/12 (TH); 09/13 (FR); 09/14 (SA); 09/15 (SU); 09/16 (MO); 09/17 (TU); 09/18 (WE); 09/19 (TH); 09/20 (FR); 09/21 (SA); 09/22 (SU); 09/23 (MO); 09/24 (TU); 09/25 (WE); 09/26 (TH); 09/27 (FR); 09/28 (SA); 09/29 (SU); 09/30 (MO)

Facility failed to provide Surveyor a copy of CASPER Report 1702D, Individual Daily Staffing Report from 1/1/24-3/31/24. (It is important to note this report would have showed the hours that were reported to CMS.)

On 1/28/25 at 11:00 AM, NHA A (Nursing Home Administrator) indicated the Corporate Office staff submit

the PBJ data to CMS. NHA A indicated the data was submitted inaccurately and because of this the facility's star rating dropped to a 1 out of 5. NHA A indicated the facility used a computer system to store PBJ data and the company went under. Then the Corporate Office staff had to manually enter the data into the CMS website. NHA A explained the Corporate Office staff entered page one data and clicked to page two. She did not press the save button. Then page two data was entered, and the Corporate Office Staff clicked to page 3 without pressing save. After page three data was entered the Corporate Office staff pressed submit thinking all three pages would be submitted, but only page three was submitted. NHA A indicated page one and page two populated with all zeroes while page three data read correctly. NHA A indicated after submitting the data

the page locks and there is no way to correct or add an addendum. NHA A indicated she understands the requirements set by CMS and the information was not reported accurately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 525508

F-F697

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50285 potential for actual harm Based on observation, interview, and record review, facility staff did not adequately assess and treat pain Residents Affected - Few and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 Residents (R) reviewed for pain (Resident R33).

The facility failed to adequately assess Resident R33's pain or provide non-pharmacologic interventions to treat her pain.

This is evidenced by:

The facility policy titled, Pain Management, dated 4/19/12 states, in part: Policy: Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. Procedure: 1. Residents shall be assessed for pain and his or her manner of expressing pain upon admission, re-admission, and annually . 3. Residents will be assessed for chronic pain or persistent pain (a pain state that continues for a prolonged period of time or recurs more than intermittently for months) when the symptoms present themselves . Plan of Care: For any resident with orders for scheduled pain management, staff will initiate an interdisciplinary plan of care based on the initial assessment and the development of pain relieving strategies. The plan will include both pharmacological and complementary interventions. Documentation: Document interventions and responses to pain management in the medical record as appropriate (i.e. medication administration record, treatment record, nursing progress notes, etc.) .

Resident R33 was admitted to the facility on [DATE REDACTED] with diagnoses that include need for assistance with personal cares, transient ischemic deafness, unspecified abnormalities of gait and mobility, generalized muscle weakness, repeated falls, rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints causing inflammation, pain, stiffness, and damage to the joints), bilateral primary osteoarthritis of the knee (a common type of joint disease that causes pain, stiffness, and swelling in the joints that occurs when the cartilage that cushions the ends of bones in the joints wears down over time), primary generalized osteoarthritis, and ankylosing spondylitis of the spine (a chronic inflammatory disease that primarily affects

the spine. It causes inflammation of the joints between the vertebrae, leading to pain, stiffness, and fusion of

the spine over time).

Resident R33's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 1/16/25 documented that Resident R33 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident R33 is cognitively intact. Section J: Health Conditions indicates that Resident R33 is on a pain medication regimen and received non-pharmacological interventions for pain. Section J0300 indicates pain is present. Section J0410 indicates pain is rarely or not at all present. Section J0600 indicates mild pain, with a numeric rating of 3.

Resident R33's Care Plan, initiated on 7/7/22, includes, in part:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Focus: [Resident Name] has an ADL (Activities of Daily Living) self-care performance deficit related to having weakness and inability to care for self . Intervention: Monitor for any signs and symptoms of pain/discomfort Level of Harm - Minimal harm or during ADLs. Date Initiated 7/20/22 . Intervention: Offer PRN (as needed) analgesics (pain relieving potential for actual harm medication) prior to ADL activities and/or rehab if indicated. Date initiated 7/20/22.

Residents Affected - Few Focus: Potential for pain related to diagnosis of Rheumatoid Arthritis, Bilateral Arthritis to knees . Intervention: Administer pain strategies according to MAR (Medication Administration Record)/TAR (Treatment Administration Record). Date initiated 7/7/22 . Intervention: Assess pain every shift. Date initiated 7/20/22 . Intervention: Complete pain assessment. Date initiated 7/20/22 . Intervention: Monitor for non-verbal indicators of pain daily with care tasks and activities. Date initiated: 7/20/22 . Intervention: Observe resident for effectiveness of pain relief. Date initiated 7/20/22 . Intervention: Offer PRN analgesics prior to ADL activities and/or rehab if indicated. Date initiated 7/20/22 . Position resident for comfort. Date initiated 7/20/22 . Reposition resident as necessary. Date initiated 7/20/22 .

Resident R33's Physician Orders Include:

Pain eval (evaluation) Q-shift (every shift). Start date: 6/30/22. No end date.

Acetaminophen 500 mg (milligram) tablet. Give 2 tablets by mouth every 6 hours as needed for fever/pain management. Start date: 12/15/22. No end date.

Acetaminophen 500 mg tablet. Give 2 tablets by mouth two times a day for pain management. Start date: 12/15/22. No end date.

Voltaren Gel 1% (Diclofenac Sodium). Apply 2 gram transdermally every 6 hours as needed for pain management. Apply to bilateral hands. Start date: 8/14/24. No end date.

Voltaren Gel 1% (Diclofenac Sodium). Apply 2 gram transdermally every 6 hours as needed for pain management. Apply to bilateral knees. Start date: 8/14/24. No end date.

Lidocaine External Patch 4% (Lidocaine). Apply to lower back topically as needed for pain management. Apply one patch on 12 hours daily. Start date: 12/30/24. No end date.

Gabapentin 100 mg capsule. Give 1 capsule by mouth at bedtime for neuropathic pain. Start Date: 1/15/25. No end date.

Resident R33's Medical Record includes, in part:

On 10/21/24 a Pain Management Evaluation states in part: . Pain Level: 0. Diagnosis: Does the resident have any diagnosis which would give you reason to believe he/she would be in pain? Yes. If yes, list: Rheumatoid Arthritis, Spondylitis of spine, Osteoarthritis of knee. What is your acceptable level of pain: 0 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 On 10/28/24, a MD (Medical Director) Progress Note states in part: . Patient admitted to the SNF (Skilled Nursing Facility) on 7/7/22 for skilled nursing and rehab. Patient asked to be seen by therapy to optimize Level of Harm - Minimal harm or therapy, pain control . Assessment/Plan: Previously noted to likely be someone who would need every 3 potential for actual harm months of knee injection for pain management. Received injections 10/9/24 and 7/9/24. Previous to that was March 2024. She reports effectiveness and success with pain control post injections . Pain, unspecified. Residents Affected - Few Patient is high risk for functional impairment without therapy and adequate pain control .No apparent distress . No new concerns .

Of note, MD Progress Notes dated 10/31/24, 11/8/24, 11/12/24, 11/21/24 state word for word the same as MD Progress Note on 10/28/24. No personalized or new interventions to address resident's pain.

On 1/9/25, a Nurse Progress Note states in part: . Resident has rheumatoid arthritis and spine is kyphotic (excessive outward curvature of the spine); gets knee injections regularly per Dr. Lynch for this; that is effective for functional decline. Resident has chronic joint pain and takes scheduled Tylenol for this which has been effective .

On 1/11/25, a Nurse Progress Note states in part: . Resident . has osteo and rheumatoid arthritis that primarily affect her knees and at times needs more assistance with ADLs. Sees Dr. Lynch regularly for knee injections that greatly improved her function .

On 1/16/25, a Pain Management Evaluation states in part: . Pain Level: 0. Diagnosis: Does the resident have any diagnosis which would give you reason to believe he/she would be in pain? No .

On 1/28/25 at 3:42 PM, Surveyor interviewed Resident R33 in her room. Resident R33 indicated that she has sharp pains in her feet and toes, and that she has told the nurses, but they don't believe her. Resident R33 stated that she tells the nurse that she wants to see the nurse about her pain, but that the nurses never come in and ask her about her pain. Resident R33 stated that this pain has been going on for over a month, and she feels ignored by staff. Resident R33 stated that she also has arthritis in her legs, and that the pain at times is a 10 out of 10. Resident R33 indicated that walking would help with her pain, but that it wasn't happening because there wasn't enough staff. Resident R33 stated that the pain was so bad that at times she wanted to sit and cry.

On 1/28/25 at 3:57 PM, Surveyor interviewed CNA/Med Tech M (Certified Nursing Assistant/Medication Technician) who stated that Resident R33 does have pain in her knees before she gets the cortisone shots. Surveyor notified CNA/Med Tech M that Resident R33 was endorsing 10 out of 10 pain. CNA M stated she would look into it.

On 1/28/25 at 4:00 PM, Surveyor interviewed CNA H who stated that Resident R33 does have ongoing pain. CNA H stated that Resident R33's pain has been so bad in her knees lately that the staff have not been walking with her much.

On 1/28/25 at 4:04 PM, Surveyor interviewed PTA O (Physical Therapy Assistant) who stated that Resident R33 does have knee pain and gets cortisone shots that does help with the pain and her mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 On 1/29/25 at 8:36 AM, Surveyor observed LPN C (Licensed Practical Nurse) administering morning medications to Resident R33. LPN C went into Resident R33's room and gave her a medication cup with her medications, then Level of Harm - Minimal harm or waited at the doorway to Resident R33's room while she waited for Resident R33 to take them. Surveyor asked LPN C if she potential for actual harm had assessed Resident R33 for pain before giving her medications. LPN C stated that she had not completed a pain assessment yet. Surveyor asked LPN C if she had marked anything in Resident R33's EHR (Electronic Health Record) Residents Affected - Few for pain. LPN C stated she had marked a zero for pain. Surveyor observed LPN C then go into Resident R33's room and utilize the whiteboard to communicate with Resident R33. (Resident R33 is deaf and reads lips or reads the white board for communication). LPN C returned from Resident R33's room and said that Resident R33 had indicated that her legs hurt bad today and she had rated her pain 9 out of 10. LPN C stated she had just given Resident R33 her scheduled acetaminophen for pain. Surveyor asked LPN C if Resident R33 had any PRN (as needed) medications for breakthrough pain. LPN C stated Resident R33 only had acetaminophen ordered, as Resident R33's pain comes and goes. LPN C stated that Resident R33 does get injections in her knees that help with her pain, mobility, and transfers, but then it wears off and Resident R33 experiences more pain again. Surveyor asked LPN C if there were any non-pharmacological interventions for Resident R33's pain, such as walking. LPN C stated she was unsure but had seen Resident R33 walking with physical therapy.

At 1/29/25 at 9:09 AM, Surveyor interviewed DON B (Director of Nursing) about Resident R33's pain. DON B indicated that Resident R33 had had previous orders for stronger narcotic medications for pain, but that Resident R33 had refused to take them. Surveyor reviewed the NP (Nurse Practitioner) progress notes in Resident R33's EHR (Electronic Health Record) with DON B. DON B stated that the NP tends to just copy and paste without reading the resident's chart, and that is a process they need to work on. Surveyor asked DON B what her expectation was for assessing resident's pain. DON B stated that she would expect the nurses to assess pain prior to giving medications. Surveyor shared with DON B her observation of LPN C not assessing Resident R33's pain, and entering

a zero for pain before assessing her, only to realize she had 9 out of 10 pain. DON B replied that sometimes Resident R33 will tell you she has 10 out of 10 pain, but when the nurses do a pain assessment she will tell them 0 out of 10.

01/29/25 at 11:06 AM, Surveyor interviewed CNA O. Surveyor asked CNA O if Resident R33 had ever complained of pain. CNA O replied yes, that Resident R33 has pain when they get her up in the morning. Surveyor asked CNA O if Resident R33 rated her pain when they were getting her up. CNA O stated no, but that she will scrunch up her face in pain and ask them to move slow because of her pain. Surveyor asked CNA O if she ever notifies the nurse of Resident R33's pain. CNA O stated no, they just move slower and give Resident R33 time to rest. Surveyor asked CNA O if she should stop and tell the nurse if Resident R33 is exhibiting pain. CNA O stated yes, she should probably get the nurse.

On 1/29/25 at 1:16 PM, Surveyor interviewed FM Q (Family Member) of Resident R33. FM Q indicated that Resident R33 has rheumatoid arthritis that is bone on bone, and very painful. FM Q stated that the steroid shots help but when

they wear off the pain is really bad. FM Q said that facility staff tell her that Resident R33 is getting old and imagining things but that Resident R33's mind is actually very sharp. FM Q stated that she feels that the facility looks at Resident R33 and her age and that she is deaf and they don't treat her like she knows what she is talking about. FM Q indicated that she thinks the facility could be doing more to address Resident R33's pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 525508 Department of Health & Human Services Printed: 09/10/2025 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 525508 B. Wing 01/30/2025

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

Alden Meadow Park Hcc 709 Meadow Park Dr Clinton, WI 53525

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 On 1/29/25 at 3:00 PM, Surveyor interviewed Resident R33 and asked her if anyone had come in and assessed her pain today. Resident R33 replied, no, that is part of the problem. Surveyor asked Resident R33 if she had walked in the hall Level of Harm - Minimal harm or today with staff. Resident R33 replied no, that no one had offered to walk with her. Surveyor asked Resident R33 if she ever potential for actual harm refused to walk due to pain. Resident R33 replied no, that she never refuses. Resident R33 again stated that therapy wants her to walk and that it helps with the pain in her legs. Resident R33 said she felt like the staff did not want to walk with her Residents Affected - Few because they didn't have time.

On 1/30/25 at 2:56 PM, Surveyor interviewed RN K. Surveyor asked RN K how she assesses Resident R33's pain. RN K replied she usually asks her, and that Resident R33 can read her lips. Surveyor asked RN K if Resident R33 ever endorsed pain greater than a 1. RN K said no, not to her.

Of note, Resident R33's documented pain ratings in the EHR have consistently been documented as 1's and 0's. In December 2024, Resident R33's MAR (Medication Administration Record) indicates six pain evaluations documented as 1 and the rest are documented as 0. In January 2025, Resident R33's MAR indicates ten pain evaluations documented as 1 and the rest are documented as 0.

On 1/30/25 at 3:19 PM, Surveyor interviewed ADON I (Assistant Director of Nursing) about Resident R33's pain. Surveyor asked ADON I what her expectation was for assessing a resident's pain. ADON I stated she would expect the staff to complete a pain assessment when the resident has signs or symptoms of pain or is reporting any pain or if they are asking for a pain medication. Surveyor asked ADON I if Resident R33 had concerns with pain. ADON I stated no, she had never heard that Resident R33 complained of pain. Surveyor reviewed Resident R33's pain assessment with ADON I and asked if the information in it was correct. ADON I replied no, that Resident R33 does have a diagnosis that would indicate pain ADON I reviewed Resident R33's EHR and confirmed that Resident R33 has rheumatoid arthritis which would indicate pain.

The facility failed to recognize and evaluate Resident R33's ongoing pain, and failed to treat her pain with appropriate pain management interventions and strategies. Resident R33's has diagnoses that indicate pain. Staff are aware that Resident R33 has unrelieved pain, and that walking can help the pain, however documentation shows that staff are often not walking with her. Resident R33 indicates that she has pain daily and that staff are not assessing or treating her pain.

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