Edgerton Care Center, Inc

F-F600 states in part; S483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. S483.12(a) The facility must-S483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 Example 1

Level of Harm - Minimal harm or Resident R46's Minimum Data Set (MDS) dated [DATE REDACTED], indicates Resident R46 scored 11 out of 15 on his Brief Interview for potential for actual harm Mental Status (BIMS) indicating he is moderately cognitively impaired. Resident R46 requires extensive assist of 2 for transferring, dressing, toileting, and hygiene. Residents Affected - Some Resident R46 was admitted to the facility 10/4/21 with diagnoses including, but not limited to, as follows: dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), major depressive disorder (persistent low mood, loss of interest or pleasure that significantly interferes with daily functioning) and low back pain. Resident R46 discharged from the facility 12/10/24 and has since passed away.

Resident R46's comprehensive care plan documents, in part, as follows: (Date Initiated: 10/4/24) Problem: Behavioral Symptoms Resident R46 is combative with cares. Goal: Resident R46 will accept cares e/b (evidenced by) cares being completed on first attempt or reapproach. Approach: .If Resident R46 becomes combative, stop cares, ensure resident is safe, leave the room, and reapproach at a later time.

Resident R46's comprehensive care plan documents, in part, as follows: (Date Initiated: 9/12/24) Problem: Resident R46 has hallucinations. Resident R46 had a diagnosis of cerebral infarction, cognitive communication deficit. Goal: Resident R46 will interact appropriately with staff, other residents, and family members. Approach: .(Date Initiated: 11/3/22) Provide safe, quiet, low-stimuli environment.

Resident R46's comprehensive care plan documents, in part, as follows: (Date Initiated: 9/12/24) Problem: Resident R46 resists ADL (Activities of Daily Living) assistance at times and can become verbally/physically aggressive towards staff. Frequent refusals to get out of bed for any length of time. Goal: Resident R46 will accept assistance for ADL's w/o (without) exhibiting resistance to care. Resistance to care pattern: verbal/physical aggression towards staff. Approach .(Date Initiated: 10/19/22) Offer resident to play game of solitaire when awake at night.

On 11/28/24 NOC shift, the following three (3) people were working together on the floor: CNA H (Certified Nursing Assistant), CNA F (Certified Nursing Assistant-Agency) and LPN G (Licensed Practical Nurse-Agency). For clarification purposes, in the statements below, CNA H is Caucasian; CNA F and LPN G are African American. The police officer did record weights of all staff involved. CNA F is smaller in stature than LPN G.

CNA H (Certified Nursing Assistant) documented the following statement: Around 1:45-2:00 AM, I was in the 1st dining room, and I heard help, help, help from Resident R46's room. I went to check on Resident R46 to see what he needed. Once I entered the room, I noticed fresh blood on his right forearm and bedding. I asked Resident R46, What happened? LPN G (Licensed Practical Nurse) followed me into the room, and Resident R46 stated, Get out of my room. LPN G left the room, and I went to find the other CNA, CNA F (Certified Nursing Assistant) who was in

the hallway walking towards me. I said to CNA F, Did you see Resident R46's arm? Come here. We both entered the room, and Resident R46 kicked her out. Once CNA F left the room, I wiped his arm with a cold washcloth. The bleeding had stopped, and he said, Thank you for helping me. I phoned the NHA A (Nursing Home Administrator) and left a voicemail at 1:54 AM advising her of the incident. The next time I entered the room was around 3:00 AM, 4:00 AM, 5:00 AM and 6:00 AM. We (meaning CNA H and the accused staff) checked, changed, and repositioned him at 4:30 AM. Resident R46 had no other comments that night.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 3/27/25 at 9:05 AM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A, when a residents reports abuse and there is an injury (bruising, bleeding, skin tear) what should staff do. Level of Harm - Minimal harm or NHA A stated, staff should immediately call me. Surveyor asked NHA A, should residents be protected. NHA potential for actual harm A stated, Oh, of course. Surveyor asked NHA A, what time did this incident occur. NHA A stated, around 2:00 AM. Surveyor asked NHA A, how soon should staff report this to you. NHA A stated, immediately. NHA Residents Affected - Some A stated, she found out about it when DON B (Director of Nursing) called her around shift change. NHA A stated, CNA H (Certified Nursing Assistant) called me and left a voicemail message during the night. NHA A stated, staff are not to just just leave me a voicemail and carry on. NHA A stated, CNA H should have called NHA A back again and tried DON B as well. NHA A stated, staff need to keep calling NHA A and DON B until

they reach one of them and NHA A and DON B will notify each other. NHA A stated, CNA H is thinking she reported it (by leaving a voicemail message). CNA H was the only other staff member working on the 3rd floor besides CNA F and LPN G.

The facility failed to immediately report an allegation of abuse, protect their residents, and immediately educate CNA H and all staff regarding reporting and restraints (physically holding a resident's hands down.)

Cross Reference:

F-F609

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49434

Residents Affected - Few Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 4 of 17 sampled residents (Resident R6, Resident R2, Resident R24, and Resident R16). Resident R6 and Resident R16 are being cited at severity level 3 (actual harm). Resident R2 and Resident R24 are being cited at severity level 2 (potential for more than minimal harm).

Resident R6 has diagnoses of neurogenic bowel (loss of normal bowel function) and constipation. The facility failed to accurately assess and monitor Resident R6 for constipation, decreased fluid intake and output as well as changes in Resident R6's mental status, resulting in frequent visits to the emergency department. The facility failed to notify Resident R6's primary care physician of his level of inadequate fluid intake and significant increases in urine output. Between 1/1/25 and 3/31/25, Resident R6 has been send to the hospital several times requiring IV (intravenous) fluid administration.

Resident R16 experienced sudden onset of four (4) projectile coffee ground emesis (forceful vomiting of dark digested blood). The facility waited 2+ hours to send Resident R16 to the ED (emergency department).

Resident R24 had a change of condition and focused assessments were not completed for continued monitoring of changes.

Resident R2 had a changes in her physical condition that were not addressed by the facility as a change in condition.

This is evidenced by:

The facility policy entitled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, dated 9/2017, states, in part: . 1. As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. This should include a review of gastrointestinal problems during any recent hospitalization s . 2. Examples of lower gastrointestinal tract conditions and symptoms include: . f. alteration in bowel movements; . h. Residents taking antidiarrheal medications or medications related to bowel mobility . 3. In addition, the nurse shall assess and document/report the following: . c. change in mental status or level of consciousness; . e. Signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status, dry mucous membranes, decreased urine output); f. Abdominal assessment; . Treatment/Management . 3. The staff and physician will address significant complications due to bowel dysfunction . Monitoring and Follow-Up . 2. The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors. 3. Before prescribing additional courses of medications, the physician should carefully evaluate and examine directly an individual who has not responded as expected to an initial course of treatment such as antidiarrheal medication, changes in the bowel regimen, etc.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 The facility policy entitled, Bowel Management Protocol, undated, states, in part: 1) NOC (Night Shift) Nurse will run the Resident Bowel Management Report in [Name of Electronic Medical Record] each NOC shift . 2) Level of Harm - Actual harm Identify all residents who have not had a bowel movement in the last 2 or more days and add them to the Nurse's Daily Bowel Report. 3) Provide Dietary department a copy of the Nurse Daily Bowel Report by 6 AM Residents Affected - Few . 4) Follow this procedure for residents with 2 or more days since last bowel movement. Day #2 No Bowel Movement -Dietary will provide a natural remedy (i.e. power pudding, prune juice, prunes, fiber cookie) with

the AM (morning) meal. Day #3 No Bowel Movement - Dietary will provide a natural remedy (i.e. power pudding, prune juice, prunes, fiber cookie) with the AM meal. -AM Nurse will complete a full bowel assessment and document a progress note in [Name of Electronic Medical Record]. - If resident has not had

a bowel movement by 12:00 PM, AM Nurse to administer 30 mL of Milk of Magnesia (Laxative that pulls water into the bowel) per Standing Orders. Day #4 No Bowel Movement -NOC Nurse will complete a full bowel assessment and administer Bisacodyl (Laxative that increases movement in the intestines) 10 mg (milligrams) suppository per Standing Orders on last rounds . then document a progress note in [Name of Electronic Medical Record]. -If a resident has not had a bowel movement by 11 AM: -Dietary will provide a natural remedy (i.e. power pudding, prune juice, prunes, fiber cookie) with the meal. -AM Nurse will complete

a full bowel assessment and document a progress note in [Name of Electronic Medical Record] and update MD (Medical Doctor) as well as resident responsible party.

The facility policy entitled, Resident Hydration and Prevention of Dehydration, dated 10/2017, states, in part: Policy Statement: This facility will strive to provide adequate hydration and to prevent and treat dehydration. Policy Interpretation and Implementation 1. The dietitian will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. 2. Minimum fluid needs will be calculated and document on initial, annual, and significant change assessments, using current standards of practice .4. The dietitian and nursing staff will educate the resident and family regarding hyderation [sic] and preventing dehydration. 5. Nurses will assess for signs and symptoms of dehydration

during daily care. 6. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily routine bases as part of daily care. a. Intake will be document in the medical records. b. Aides will report intake of less than 1200 ml (milliliters)/day to nursing staff . 8. Orders may be written for extra fluids to be encouraged between meals and/or with medication passes. a. A specific minimum amount should be included in the order . 9. The dietitian, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake . 12. Nursing will monitor and document fluid intake and the dietitian will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are resolved.

According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:

(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.

(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled Level of Harm - Actual harm assistants.

Residents Affected - Few (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.

According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider .

(b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes

in the condition of a patient .

(e) Perform the following other acts when applicable:

1. Assist with the collection of data.

2. Assist with the development and revision of a nursing care plan.

3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction.

4. Participate with other health team members in meeting basic patient needs.

Example 1:

Resident R6 was admitted to the facility on [DATE REDACTED], with diagnosis that include, in part: heart failure, epilepsy (seizure disorder), generalized anxiety disorder, cerebral infarction (stroke), hypertension (high blood pressure), history of cardiac arrest (heart stops beating), presence of other cardiac implants and grafts. hereditary spastic paraplegia (group of hereditary disorders causing progressive, spinal, spastic leg muscle weakness), MELAS syndrome (genetic disorder causing muscle weakness, seizures and stroke-like episodes), neurogenic bowel (loss of normal bowel function due to a nerve problem), and constipation.

Resident R6's Minimum Data Set (MDS), with Assessment Reference Date of 3/12/25, states that Resident R6 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating that Resident R6 is cognitively intact. Section GG indicates Resident R6 utilizes a manual wheelchair and mechanical lift for mobility. GG0115 indicates Resident R6 has impairment on both his right and left lower extremities. GG0130 indicates he is independent for eating, and dependent on staff for toileting hygiene, showering and bathing, and lower body dressing. GG0170 indicates Resident R6 is dependent on staff for rolling left and right, transferring between a chair and a bed, and transferring to a toilet is marked not applicable. Section H indicates Resident R6 has an indwelling catheter. H0400 indicates Resident R6 is always incontinent of bowel. H0500 indicates that a toileting program is currently being used to manage Resident R6's bowel continence. H0600, which asks if there is constipation present is not complete. Section K indicates Resident R6 has no signs or symptoms of a swallowing disorder.

Resident R6's Comprehensive Care Plan states, in part:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 Problem: Potential for dehydration r/t (related to) frequent episodes of N/V (nausea/vomiting), recurrent UTI's (urinary tract infections), periods of lethargy with refusals of meals/fluids. Problem Start Date: 12/10/24. Level of Harm - Actual harm Approach: Frequent oral cares d/t (due to) emesis (vomiting) and dehydration. Approach Start Date: 1/23/25. Residents Affected - Few Approach: Assess for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry mucus membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance). Approach Start Date: 12/10/24.

Approach: Document any and all refusals for this resident. Approach Start Date: 12/10/24.

Approach: Encourage fluids of choice. Keep iced water cup filled at bedside. Approach Start Date: 12/10/24.

Approach: Record intake and output every shift. Approach Start Date: 12/10/24.

Approach: Update wife every shift if resident has any nausea or vomiting, poor intake and any other changes. Approach Start Date: 12/10/24.

(Of note: This problem was created on 12/10/24, with all approaches starting the same day except for frequent oral cares which started 1/23/25. No additional approaches or interventions were put in place to improve Resident R6's fluid intake, even with multiple hospitalization s.)

Problem: Resident has potential for constipation R/T (related to) decreased mobility. Problem Start Date: 11/18/16. Problem End Date: 7/11/23. Edited: 2/25/25.

Goal: Resident will have a regular, soft-formed bowel movement at least every 3rd day. Long Term Goal Date: 5/25/25.

Approach: Follow bowel protocol as needed. Approach Start Date: 3/1/23.

Approach: Monitor unbilical for any changes in hernia type protruding area, pain or change in bowel movements. Update MD if changes. Approach Start Date: 6/28/18.

Approach: Administer medications per MD order. Monitor effectiveness and side effects. Approach Start Date: 11/18/16.

Approach: Document frequency and character of bowel movements. Approach Start Date: 11/18/16.

Approach: Encourage fluids of choice. Approach Start Date: 11/18/16.

Approach: Monitor for signs of constipation such as decreased bowel sounds/abdominal pain/distension/decreased appetite/fever, etc. Approach Start Date: 11/18/16.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 (Of note: This problem start date is indicated to be 11/18/16 and no approaches or interventions were put in place after 3/1/23. Also of note, this problem is indicated to have an end date of 7/11/23.) Level of Harm - Actual harm Problem: Resident requires supra pubic catheter R/T DX (Diagnosis): neurogenic bladder (bladder control is Residents Affected - Few affect due to nerve damage). HX (History): chronic, frequent UTI's.

Approach: Encourage fluids of choice. Water mug within reach and encouraged to drink every 2 hours. Family supplies [Brand Name] packages to flavor water. Approach Start Date: 3/12/25.

Approach: Record catheter output amount. Change catheter per [Doctor's Name] orders only. Approach Start Date: 9/21/21 .

Problem: Basic CNA (Certified Nurse Assistant) Care Plan. Problem Start Date: 9/13/24.

Approach: . Transfers: Hoyer and assist of 2 . Grooming/Dressing/Toileting: . Extensive assist with hygiene and dressing. Supra pubic catheter. Incontinent of bowel. Provide incontinence care after each incontinence episode . Behavior and Cognition: Pleasant and cooperative . Approach Start Date: 9/13/24.

(Of note, this care plan does not indicate Water mug within reach and encouraged to drink every 2 hours.)

Resident R6's Physician Orders state, in part:

Benefiber (Fiber Supplement, Supports Digestive System) Clear SF (dextrin) (wheat dextrin) powder in packet; 3 gram/3.5 gram; amt (amount): 2 tsp (teaspoons); oral, Once a day, 12:00 PM. Start Date: 11/14/24. End Date: 1/30/25. Start Date: 1/30/25. End date: 3/24/25.

Bisacodyl (Laxative that increases movement in the intestines) [OTC] (Over the Counter) suppository; 10 mg (milligrams); amt: 1 suppository (solid dosage form inserted into the rectum where it dissolves or melts to deliver medication); rectal. Special Instructions: Give at 8 pm and 5 am daily. Twice a day. 20:00 (8:00 PM), 04:00 (4:00 AM). Start Date: 11/16/24. End Date: 1/10/25.

Bisacodyl [OTC] (Over the Counter) suppository; 10 mg (milligrams); amt: 1 suppository; rectal. Special Instructions: Give at 8 pm and 4 am daily (may be given at 3A (3:00 AM) if awake). Twice a day. 20:00 (8:00 PM), 04:00 (4:00 AM). Start Date: 1/10/25. End Date: 1/30/25.

Bisacodyl [OTC] (Over the Counter) suppository; 10 mg (milligrams); amt: 1 suppository; rectal. Special Instructions: Insert 1 suppository to equal 10 mg per rectum BID (twice a day) at[sic] 8 pm and 4 am daily (may be given at 3A if awake). [NAME] a day. 20:00, 04:00. Start Date: 1/30/25. End Date: 3/24/25.

Bisacodyl [OTC] tablet, delayed release (DR/EC); 5 mg; amt: 1 tab daily; oral. Special Instructions: Take one tablet daily. Once a day. 06:30-10:00. Start Date: 9/19/24. End Date: 1/30/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 Bisacodyl [OTC] tablet, delayed release (DR/EC); 5 mg; amt: 1 tab daily; oral. Special Instructions: Take one tablet to equal 5 mg daily X 360 doses. Once a day. 06:30 - 10:00. Start Date: 1/30/25. End Date: 1/25/26. Level of Harm - Actual harm Docusate sodium (stool softener that increases the amount of water the stool absorbs in the gut to treat Residents Affected - Few constipation) [OTC] tablet; 100 mg; amt: 200 mg; oral. Special Instructions: Give Docusate Sodium 200 mg BID (twice a day). Twice a day. 06:30 - 10:00, 18:30 - 22:30 (6:30 PM - 10:30 PM). Start Date: 12/5/24. End Date: 1/30/25. Start Date: 1/30/25. End Date: 3/24/25.

Electrolyte (Electrolyte Supplement) Fast Chew tablet; 0.5 (3.3g); amt: 1; oral. Once a day. 06:30-10:30. Start Date: 6/22/24. End Date: 1/30/25.

Electrolyte Fast Chew tablet; 0.5 (3.3g); amt: 1; oral. Special Instructions: Take 1 tab to equal 3.3 g daily. Once a day. 06:30-10:30. Start Date: 1/30/25. End Date: 3/24/25.

Fleet Enema (sodium phosphates) (draws water into colon and rapidly produces a bowel movement) [OTC] enema (introduction of liquid through rectum into the large intestine to treat constipation); 19-7 gram/118 mL (milliliters); amt: 133 mL; rectal. Special Instructions: Insert 133 mL into rectum daily PRN (as needed) for constipation. As needed. PRN 1 (as needed once per day). Start Date: 1/30/25. End Date: 3/24/25.

Milk of Magnesia (Laxative that pulls water into the bowel) (magnesium hydroxide) [OTC] suspension; 400 mg/5 mL; amt: 30 ml; oral. Special Instructions: daily prn for constipation. As needed. PRN 1. Start Date: 6/22/24. End Date: 1/30/25.

Milk of Magnesia (Laxative that pulls water into the bowel) (magnesium hydroxide) [OTC] suspension; 400 mg/5 mL; amt: 30 ml; oral. Special Instructions: Take 30 mL daily PRN for constipation. As needed. PRN 1. Start Date: 1/30/25. End Date: 3/24/25.

Miralax (Laxative that draws water into the bowels) (polyethylene glycol 3350) [OTC] powder; 17 gram/dose; amt: 17 grams; oral. Special Instructions: MIX IN ORANGE JUICE PER RESIDENT REQUEST. Once a Day

on Mon (Monday). 11:00 - 13:00 (1:00 PM). Start Date: 6/22/24. End Date: 1/30/25.

Miralax (polyethylene glycol 3350) [OTC] powder; 17 gram/dose; amt: 17 grams; oral. Special Instructions: RESIDENT WOULD LIKE MIRALAX MIXED WITH ORANGE JUICE. MIX WITH METAMUCIL AS WELL AND TELL RESIDENT WHAT HE IS RECEIVING PER FAMILY. Hold if having loose stools. Twice a day. 06:30 - 10:30, 18:00 - 22:30. Start Date: 6/22/24. End Date: 1/30/25. Start Date: 1/30/25. End Date: 3/24/25. Start Date: 3/25/25.

Senna Plus (Keeps water in the intestines which increases movement in the intestines and treats constipation) (sennosides-docusate sodium) [OTC] tablet; 8.6-50 mg; amt: 17.2 - 100 mg; oral. Special Instructions: Give Senna Plus 2 tablets daily. Hold if having loose stools. Twice a day. 06:30 - 14:00 (2:00 PM), 18:30 - 22:00. Start Date: 6/22/24. End Date: 1/30/25.

Senna Plus (sennosides-docusate sodium) [OTC] tablet; 8.6-50 mg; amt: 17.2 - 100 mg; oral. Special Instructions: Take 2 tabs to equal 17.2 - 100 mg daily. Hold for loose stools. Once a day. 06:30 - 14:00 (2:00 PM). Start Date: 1/30/25. End Date: 3/24/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 Soap suds enema (Irritates the lining of the colon which stimulates bowel contractions and encourages person to release contents of their bowel) enema; warm soap suds; at least 500 ml; rectal. Special Level of Harm - Actual harm Instructions: if no results from scheduled bisacodyl suppositories given at HS (bedtime) and 0400 (4:00 AM), sign out and give warm soap suds enema if no results from suppositories. As needed. PRN 1. Start Date: Residents Affected - Few 1/12/25. End Date: 2/3/25.

Soap suds enema, enema; warm soap suds; amt: at least 500 ml; rectal. Once a day. 10:00 (10:00 AM). Start Date: 2/4/25. End Date: 2/10/25.

Sodium chloride 0.9% (IV Fluid Replacement) parenteral (intravenous) solution - ; amt: 125 ml/hr (milliliters/hour) over 16 hours; intravenous. Special Instructions: Order updated since resident had a liter of fluids while at the ER (emergency room ). Now run 0.9% sodium chloride at 125 ml/hr over 24 hours; intravenous. Once - One Time. 22:00 (10:00 PM). Start Date: 1/22/25. End Date: 1/22/25.

Encourage fluids every shift. Every Shift; day, pm, noc. Start Date: 1/18/23. End Date: Open Ended.

UPDATE WIFE EVERY SHIFT IF RESIDENT HAS ANY NAUSEA OR VOMITING, POOR INTAKE, AND ANY OTHER CHANGES. Special Instructions: call if output less than 3000 ml in 24 hrs, call if input is less than 64 oz. Every Shift; day, pm, noc. Start Date: 11/4/24. End Date: Open Ended.

(Of note: This list contains 5 different medications that either draw water into the colon or prevent the body from absorbing water from the colon.

On 12/10/24 at 21:57 (9:57 PM), a Progress Note is written that states, in part: Notes from [Physician's Name] visit today: Make sure he has 64 oz (ounces) (1,893 milliliters) of fluid daily . please keep track of urine output daily . chronic constipation, continue with current bowel regimen and fluid intake .

On 12/11/24 at 14:39 (2:39 PM), a Progress Note is written by LPN S (Licensed practical Nurse), that states,

in part: .He did not have a BM (bowel movement) from scheduled Bisacodyl suppository given on noc (night) shift. PM (Evening) nurse aware. Resident drank 480 ml at both meals and drank 360 ml water with med passes. He was drinking his flavored ice water in his personal water bottle. He drank approximately 16 oz (473 ml) by the end of this shift .

(Of note, no bowel assessment is indicated as being done)

On 12/27/24 at 12:32 PM, a Telephone Note is written by a clinic RN, that states, in part: .Note from 12/10/24 visit: 1. Constipation -Return to previous bowel regimen: bisacodyl suppository twice daily (morning and night) . -Encourage fluid intake goal of 64 ounces daily (two 32[sic]-ounce containers) .

Resident R6's Fluid Intake is care planned to be documented every shift.

From 1/1/25 to 3/25/25, Resident R6 had no fluid intake documented for 15 different days. In a physician's note to the facility, the physician reports Resident R6 requires 64 oz (1,893 mL) every day to maintain hydration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 From 1/1/25 to 3/25/25 Resident R6 never reaches his fluid intake goal. The most fluid intake that Resident R6 had in a single day, according to facility documentation, was 1,360 mL. Level of Harm - Actual harm

On 1/1/25 at 13:43 (1:43 PM), a Progress Note is written by LPN S, that states, in part: Resident had large Residents Affected - Few BM as a result of scheduled Bisacodyl suppository given by noc nurse . Resident offered no c/o pain, SOB (shortness of breath) or feeling ill .

On 1/1/25, Resident R6 consumed 480 mL of fluid, according to the fluid intake record. The resident is documented to have a large bowel movement at 14:43 (2:43 PM).

On 1/2/25 at 13:34 (1:34 PM), a Progress Note is written that states: Resident was lethargic and hard to arouse all morning, writer entered room on 3 separate occasions to evaluate VS (vital signs) wnl (within normal limits), resident would raise head, open and close eyes, lower head, no response to questions, after

the third time, I s/w (spoke with) his wife who agreed that we should send him to the hospital, about an hour later (at which point we were waiting for transport,), resident awoke and claimed to feel fine.

(Of note: No bowel assessment documented prior to transport)

On 1/2/25 at 15:43 (3:43 PM), a Progress Note is written by RN AA (Registered Nurse), that states, in part: Resident left facility at this time via [EMS Agency Name] EMS .

On 1/2/25 at 23:15 (11:15 PM), Resident R6 is documented to have a large bowel movement.

On 1/2/25 at 23:23 (11:23 PM), a Progress Note is written by RN Z, that states, in part: Resident returned from ER (emergency room ) visit at PM/NOC (Evening/Night) cross shift. Resident recorded not to have had

a bowel movement since 1/1/25. Resident given a prn warm water soap suds enema of 750 ml which produced an x (extra) large liquid and soft formed stool bowel movement. After getting cleaned up, resident was given his scheduled PM shift bisacodyl suppository.

On 1/4/25, Resident R6 consumed 240 mL of fluid, according to the fluid intake record. The resident did not have a bowel movement.

On 1/5/25, Resident R6 consumed 480 mL of fluid, according to the fluid intake record. The resident is documented to have a large bowel movement at 14:00 (2:00 PM).

On 1/6/25, no fluid intake is documented for Resident R6. The resident is documented to have a small bowel movement at 20:56 (8:56 PM) and a large bowel movement at 23:03 (11:03 PM).

On 1/6/25 at 23:08 (11:08 PM), a Progress Note is written by RN Z, that states, in part: Called to resident's room by CNA (Certified Nursing Assistant) stating that resident had a large emesis. Resident observed to have a large projectile emesis that was liquid brown in color with some small amounts of brown colored sediment that was highly suspicious of stool. Staff had been in resident's room to clean him up after him having a large liquid brown stool from his late PM shift scheduled bisacodyl suppository . Resident was alert and able to answer simple questions, but appeared worn out and very tired . Resident stated he drank very little for fluids . Phone call to [Physician Name] who was on call for [Physician Name] and permission to send resident to [Hospital Name] ER for evaluation .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 (Of note: No lung or bowel assessment documented prior to transport).

Level of Harm - Actual harm On 1/7/25 at 03:46 AM, a Progress Note is written by RN Z, that states, in part: Phone call from [Hospital Name] ER and spoke with nurse caring for resident. Resident is being admitted for some more labs and Residents Affected - Few possible ABX (antibiotic) TX (treatment)

On 1/9/25 at 14:18, a Progress Note is written by RN BB that states, in part: Resident returned via stretcher from hospitalization [Hospital Name] discharge dx (diagnosis): Pneumonia .

On 1/19/25 at 15:33 (3:33 PM), a Progress Note is written by RN BB that states, in part: 600 ml warm water/[NAME] soap enema given at 1530 (3:30 PM) producing large bowel movement-soft, formed . Resident's fluid intake has been only fluids at meals and with meds

(medications) .

On 1/20/25, Resident R6's fluid intake was not recorded. Total urine output was 950 mL. The resident is not documented to have a bowel movement on this day.

On 1/20/25 at 13:04 AM (1:04 PM), a Progress Note is written by LPN R that states, in part: Small emesis of yellow bile after enema this am . Denies pain. Drank 240 this am and 720 this afternoon. Working on water bottle in room at this time.

On 1/21/25, Resident R6's fluid intake was not recorded. Total urine output was 1,600 mL. The resident is not documented to have a bowel movement on this day.

On 1/21/25 at 10:35 AM, a Progress Note is written by LPN R that states, in part: Resident lethargic this am (morning). Responds appropriately to verbal stimuli. Opens eyes to commands but falls back to sleep. Decline breakfast stating he is sick to stomach at this time. PRN (as needed) Zofran (anti-nausea medication) administered. Up in recliner at this time .

On 1/21/25 at 13:56 (1:56 PM), a Progress Note is written that states, in part: Called [Physician Name]'s office regarding resident vomiting for 2-3 days, has not held anything down today, including morning meds and has been unable to stay awake. Writer concerned about dehydration . (of note, there is no indication if

this author was an LPN or an RN)

(Of note: There is only one prior note in the past 2-3 days referencing vomiting. No abdominal assessments were conducted during the past 2-3 days. Resident R6 did not have a bowel movement on 1/20 or 1/21 per charting above.)

On 1/22/25 at 10:04 AM, an After Visit Summary was printed that lists the diagnosis as: Nausea and Vomiting, unspecified vomiting type.

On 1/21/25 at 23:13 (11:13 PM), a Progress Note is written that states, in part: Res returned from the hospital around 1900 (7:00 PM) via EMS on a stretcher. EMS reported that res had emesis coming up the elevator . BP (Blood Pressure) 98/46 . p (pulse): 56 . RR (Respiratory Rate) 22 . Res BP was rechecked later

in the shift, with a BP reading of 100/57. Res was encouraged to increased fluid intake .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 (Of note: No abdominal assessment or bowel sounds recorded.)

Level of Harm - Actual harm On 1/22/25, Resident R6's fluid intake was documented as 30 mL. Total urine output was 900 mL, indicating a fluid loss of 870 mL. The resident is not documented to have a bowel movement on this day. Residents Affected - Few (Of note: Resident R6 did not have a BM on 1/20, 1/21 or 1/22 per charting)

On 1/22/25 at 06:31 AM, a Progress Note is written by RN Z that states, in part: Resident lethargic this morning and minimally responsive to verbal commands to where it was unsafe for him to take his early morning meds. Resident[sic] has not had any results from his bisacodyl suppository administered at 0400am (4:00 AM) or on the PM shift. Resident vitals all within normal limits with exception of a pulse that seems slower than his usual . Order given to send to resident in to [Hospital Name] ER for evaluation again. Note resident has not had a reported or recorded BM since 1/19/25. When paramedics arrived to transport, resident responded enough to try and drink a small amount of water which almost immediately came [sic] back up. Resident had 200 ml emesis .

On 1/22/25 at 10:04 AM, an After Visit Summary was printed from Resident R6's ER visit that lists the diagnosis as nausea and vomiting, unspecified vomiting type.

On 1/22/25 at 15:09 (3:09 PM), a Progress Note is written by LPN S that states, in part: Writer learned of resident's return to facility via [EMS Agency Name] service as he arrived to unit . He opened his eyes here and there but did not keep them open for any length of time . He opened his eyes to verbal stimuli but did not keep them open for too long. He did take noon med crushed in pudding but needed verbal cues to swallow

the pudding once it was in his mouth. His mouth was so dry upon return that he was unable to suck on a straw so writer used the straw to put water in the side of his cheek which he was able to swallow w/o difficulty. Resident declined lunch . Just before the end of shift he drank 180 ml water that writer offered. He has had no emesis since .

(Of note: No abdominal assessment was recorded over this time period. Additionally, the LPN notes signs of dehydration at this time, however Surveyor was unable to locate an RN assessment in reference to these concerns.)

On 1/22/25 a Physician's Order is placed that states, in part: Send to [Hospital Name] ER for IV placement so resident can have his ordered IV fluids x 24 hrs. STAT - Immediately. STAT. Start Date: 1/22/25. End Date: 1/22/25.

(Of note: an RN is licensed and trained to place IV's as part of the licensure process.)

On 1/23/25 at 00:29 (12:29 AM), a Progress Note is written by RN Z that states, in part: [EMS Agency Name] arrived to transport resident to [Hospital Name] ER[sic] for IV placement. Resident had a medium emesis of yellow thin fluid .

On 1/23/25 at 02:30 (2:30 PM), a Progress Note is written by RN Z that states, in part: . Resident had IV (intravenous) placed and they gave him a liter of fluid in the hospital. Will continue to administer the remainder of the fluids (2 liters) upon resident's return.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0684 On 1/23/25 at 04:16 (4:16 AM), a Progress Note is written by RN Z that states, in part: Resident has not had

a recorded bowel movement since 1/19/25. PRN 750 ml warm soap suds enema was given in lieu[sic] of Level of Harm - Actual harm scheduled bisacodyl suppository. Resident did not appear to have any results immediately from the enema only expelling stool colored water. Residents Affected - Few (Of note: Facility continues to acknowledge resident has not had a bowel movement, and it has now been 4 days since Resident R6's previous bowel movement. Additionally, no bowel assessment has been conducted.)

On 1/23/25 at 04:49 (4:49 AM), a Progress Note is written by RN Z that states, in part: Resident returned from [Hospital Name] ER . Resident has IV placed in left hand and reported to have received a liter[sic] of fluids while in the ER . had IV fluid order updated to infuse at 125ml/hr (milliters/hour) for sixteen hours.

On 1/23/25 a Physician Order is placed that states, in part: Frequent oral cares d/t emesis and dehydration. Every shift. day, pm, noc. Start Date: 1/23/25. End Date: 1/25/25.

On 1/23/25 at 12:20 PM, a Progress Note is written by LPN R that states, in part: Called to resident room at 1130 (11:30 AM). Resident with moderate amount of[sic] bile emesis present . [EMS Agency Name] picked resident up at 1200 (12:00 PM) for transport to [Hospital Name] .

(of note: no evidence of an RN assessment being completed)

On 1/23/25 at 16:38 (4:38 PM), a Progress Note is written that states, in part: [Hospital Name] RN called to request the medication record to be faxed to [phone number] . RN stated patient is admitted as admitting diagnosis was Altered Mental Status with S&S (Signs and Symptoms) of Confusion, Cough, and Nausea .

On 1/27/25 at 11:50 AM, a Progress Note is written by RN BB that states, in part: Discharge diagnosis listed emesis and constipation .

(no evidence of continued monitoring or assessments being completed on Resident R6 after returning from the hospital other than documenting if Resident R6 had N/V or not.)

On 1/29/25 at 14:01 (2:01 PM), a Progress Note is written by LPN S that states, in part: . He received prn Soap Suds Enema from [LP[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39849

Residents Affected - Few Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 5 resident (Resident R24 and Resident R2) reviewed.

Resident R24 was observed not disposing of cigarette materials properly and not returning materials to staff after returning from smoking.

Resident R2 has had eight falls from 1/6/25 - 3/13/25 and has several care planned interventions including Dycem (a non-slip product that grips on both sides placed in a resident's wheelchair to prevent sliding out), gripper socks to be on resident's feet when out of bed, gripper strips on the floor, a mat on the floor by the bed, and shoes to be kept in the wheelchair at bedside when resident was in bed. The facility did not ensure these interventions were in place to prevent Resident R2 from having further falls.

Example 1:

The undated facility policy, Smoking Policy and Procedure, indicates, in part: Policy: It is the policy of [NAME] Care Center to provide for the safety and welfare of all residents who wish to smoke while residing at the facility. Procedure: .2. Residents shall be permitted to smoke outside, in the designated area, only under the direct supervision of facility employee, approved volunteer, or with a family member, unless they are assessed to be safe to smoke independently by the Interdisciplinary Team .4. Smoking articles, such as cigarettes, e-cigarettes, cigars, pipes, tobacco, and lighters shall be kept at the Nurses Station. 5. Smoking articles may be checked out when leaving the facility and checked back in upon return to the facility. 6.

These regulations shall be followed by the resident at all times .

Resident R24 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Unspecified intestinal obstruction; Acquired absence of other specified parts of digestive tract; Colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall to divert stool from the colon (large intestine) to an external bag); Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and mood disorders (depression or bipolar disorder); and Nicotine dependence .

Resident R24's most recent Minimum Data Set (MDS), target date 2/19/25, indicates a Brief Interview of Mental Status (BIMS) of 11. Indicating that Resident R24's cognition is moderately impaired.

On 3/24/25 at 11:48 AM, during the initial screening process, Surveyors observed a partial cigarette on Resident R24's bedside table. Resident R24 indicated he is currently independent with smoking and that someone came out with him when he first came and watched him and told him he didn't need anyone with him when he went out to smoke. Resident R24 indicated he gets his cigarette and lighter from the nurse and gives the lighter back when he comes back in. Resident R24 indicated he does not smoke a whole cigarette at a time.

Surveyors reviewed Resident R24's smoking assessments in the EHR (Electronic Health Record).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0689 1/28/25 - Smoking assessment -- Score = 0

Level of Harm - Minimal harm or 2/24/25 - Smoking assessment -- Score = 1 potential for actual harm 3/12/25 - Smoking assessment -- Score = 6 Residents Affected - Few Of note, the smoking score scale indicates a score of 0-9 is a safe smoker.

Surveyors reviewed Resident R24's progress notes, which include, in part:

On 2/4/2025 at 8:44 AM: Writer met with resident in lounge to discuss getting lighter to lock up in med cart. Resident .was calm during discussion and gave writer the lighter to lock up. Writer gave resident lighter to med tech to lock up .

On 2/4/2025 at 10:18 AM: Noted that lighter is not in med cart this morning, updated SW D/T (due to) behaviors R/T (related to) lighter and smoking yesterday. Resident gave SW lighter, and it is back in med cart .

On 2/5/2025 at 9:27AM: Resident up and outside this morning before breakfast. Resident returned to his room after breakfast. Writer found resident laying in bed and asked about his lighter. Resident rolled his eyes at writer. Writer reminded resident of policy and the need for compliance D/T fire safety. Resident responded, I came back, didn't I? Re-iterated policy, resident verbalizes understanding .

On 2/7/25 at 9:20 AM: .Resident provided one cigarette and his lighter to go outside, did not return lighter upon return to unit and writer had to track him down to lock it back up .

On 3/21/25 at 6:15 PM: Resident sitting near nurses station .Distinct odor of partial cigarettes. Writer inquired if he had a partial cigarette. Resident laughed and stated, you got a keen sense of smell. Writer asked that

he turn in his partial cigarette and lighter or go back outside to smoke it. Resident turned in lighter and 3 partial cigarettes.

On 3/26/25 at 4:04 PM Surveyors interviewed RN T (Registered Nurse) who indicated when she is working

she will give Resident R24 his cigarette and lighter and he brings the lighter back after he is done smoking. Surveyors asked RN T if she has ever asked Resident R24 if he finished his full cigarette. RN T indicated, no. Surveyors asked RN T if she has ever seen a partially smoked cigarette sitting in his room. RN T indicated, no.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0689 On 3/26/25 at 4:16 PM Surveyors observed Resident R24 when he went outside to smoke. Surveyors interviewed Resident R24

during the observation. Resident R24 indicated he tosses his cigarette butts in the driveway of the facility and Level of Harm - Minimal harm or sometimes he puts them in the ashtray. There are multiple cigarette butts noted in the facility driveway. (Of potential for actual harm note, there is an ashtray on one of the patio tables without any ash or cigarette butts in it. ) Surveyors asked Resident R24 if he was told how to dispose of his cigarette and Resident R24 initially stated he was supposed to use the Residents Affected - Few ashtray, then stated they told him to put it out, and then stated, [NAME], I don't remember. Surveyor asked Resident R24 if he goes to talk to the nurse when he is done smoking. Resident R24 indicated, he gives her his lighter and that sometimes before he goes back up he sits in the lobby because he likes to listen to the music. Surveyor asked Resident R24 if he always gives his lighter to the nurse when he is done and Resident R24 indicated sometimes he forgets. Surveyor asked Resident R24 if staff then comes and asks him for the lighter and Resident R24 indicated, yeah, it's a long story. During the observation Resident R24 was noted to be flicking his cigarette ashes onto the cement where he sits and stated this is common for him to do. Resident R24 put his cigarette out on the metal chair he was sitting in and threw the butt into the facility driveway. (Of note, Resident R24 did complete the full cigarette) Resident R24 then walked back into the facility and sat in a chair in the lobby without going upstairs to return his lighter. Surveyors continued to observe Resident R24.

On 3/26/25 at 4:40 PM Surveyors observed Resident R24 leave the lobby and return to the 2nd floor. Resident R24 went to the nurses station, looked into nurses station and proceeded to go to his room. Surveyors continued to observe Resident R24.

On 3/26/25 at 5:05 PM Resident R24 was still in his room and surveyors then interviewed RN T. Surveyors asked RN T how long she waits after providing smoking materials before she checks to see if Resident R24 has returned from smoking? RN T indicated that Resident R24 sits downstairs for a while and she would probably wait 30 minutes. Surveyors asked RN T if she had his lighter and she indicated she did not. Surveyors reviewed the smoking

observations made with RN T. RN T went to Resident R24's room and she indicated he gave the lighter to her and showed it to surveyor.

On 3/27/25 at 8:47 AM Surveyors interviewed NHA A (Nursing Home Administrator) who showed surveyors where the designated smoking area is outside and indicated residents should be disposing of cigarettes in

the ashtray. Surveyors reviewed information from Resident R24's smoking observation with NHA A. Surveyors asked NHA A if Resident R24 should be flicking ashes onto the ground, putting his cigarette out on the chair, and throwing

the butt into the facility driveway. NHA A indicated, no. Surveyors asked NHA A if it is the expectation that Resident R24 give his lighter back to the nurse right away. NHA A indicated, it is, but that he does go in and sit in the lobby before he takes it up to the nurse. Surveyors asked NHA A how long she would expect staff to wait

before checking with Resident R24 if they he hasn't returned the lighter. NHA A indicated 30-45 minutes. Surveyors asked NHA A if she feels it is safe for Resident R24 to be independent given the way he is disposing of ashes, his cigarette, and not returning the lighter right away. NHA A indicated, no. Surveyor asked NHA A if she was aware the progress notes in Resident R24's chart indicating staff having to go get the lighter from Resident R24. NHA A indicated, I'm sure they do have to do that.

On 3/27/25 at 12:45 PM Surveyors interviewed NHA A and reviewed observation of partial cigarette on over

the bed table and then reviewed 3/21 note where it indicates staff knew he was keeping partial cigarettes. NHA A indicated with that knowledge staff should be asking Resident R24, when he returns, if he has a partial cigarette to turn in.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0689 On 3/31/25 at 8:48 AM Surveyors interviewed DON B (Director of Nursing) and asked what the process is for determining if someone is safe to smoke independently. DON B indicated, we have a nurse do an Level of Harm - Minimal harm or assessment and they are done quarterly. Surveyors asked if the assessment is the only thing they use to potential for actual harm determine if the resident is safe to smoke independently. DON B indicated, when the assessment is done,

they look at the BIMS (Brief Interview of Mental Status), because they can be ok today and not ok tomorrow, Residents Affected - Few and they go outside with the resident and make sure they can smoke safely. Surveyors asked DON B where residents should put ashes and the cigarette after smoking. DON B indicated there is an ashtray out there and that is part of the assessment, they have to be able to put it in the ashtray. Surveyors asked DON B if someone is safe to smoke independently if they don't return their smoking materials after, are disposing of ashes on the ground and disposing of the cigarette butt on the ground. DON B indicated, no. Surveyors asked DON B if staff are noting that a resident is not returning smoking materials and are keeping partially smoked cigarettes, what would you expect staff to do. DON B indicated, they should notify LPN V (Licensed Practical Nurse) so she can repeat the assessment and provide education.

Surveyors reviewed, with DON B, information from the chart that indicated staff were having to ask Resident R24 to return his lighter. Surveyors read the note from 3/21 regarding the partial cigarettes and lighter in Resident R24's possession. Surveyors asked DON B if Resident R24 should be independent with smoking knowing he is doing these things. DON B indicated, probably not.

50285

Example 2:

The facility's policy entitled, Falls - Clinical Protocol, dated 2001, indicates, in part: . Cause Identification: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . 2. If the cause of a fall is unclear, . or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors . 3. The staff and physician will continue to collect and evaluation information until either the cause of the falling is identified . Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences to falling . 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation . Monitoring and Follow-up: . 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling . 4. If he individual continues to fall, the staff and physician will reevaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to, those that have already been identified) and also reconsider the current interventions .

Resident R2 admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Unspecified dementia, severe, with mood disturbance,, Acute kidney failure, unspecified, Altered mental status, Unsteadiness on feet, Muscle wasting and atrophy, Low back pain, and Epilepsy unspecified.

Resident R2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/7/25 indicates BIMS (Brief Interview of Mental Status) score of 00 out of 15, indicating Resident R2 has severe cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0689 Resident R2's fall care plan, includes, in part:

Level of Harm - Minimal harm or -Problem: HX (history) of multiple falls. At risk for further falls r/t (related to) impaired balance, decreased potential for actual harm strength and activity tolerance, decreased functional mobility skills, decreased safety awareness. Start Date: 12/20/2017. Revision Date: 3/24/2025 Residents Affected - Few -Approach: 2 assist, gait belt for squat pivot transfers. staff to assist with WC (wheelchair) mobility. Start Date: 3/10/25. Revision Date: 3/22/25.

-Approach: WC delivered from (company name). Start Date: 3/10/25. Revision Date: 3/22/2025

-Approach: Trial pool noodle on outer side of bed to remind resident where edge of bed is to prevent rolling out of bed. Start Date: 3/14/2025

-Approach: Keep WC close to bed. 3/12/2025

-Approach: Air flow cushion to WC and/or recliner with Dycem to be placed under cushion. Start Date: 3/10/25. Revision Date: 3/11/25

-Approach: Scheduled toileting every 2-3 hours with 2 assist, gait belt. Resident to be checked every 1-2 hours at noc (nighttime) and if awake assist with toileting. Resident should be toileted with HS (bedtime) blood sugar check when awakened or check blood sugar prior to going to sleep and HS cares. Start Date: 3/10/2025

-Approach: Resident has roommate and is more receptive to attend meals and have cares done

-Approach: When assisting roommate check to ensure that [Resident Name] has basic needs met i.e., toileting, room safety, H20 (water), hygiene needs, etc. Provide increased supervision during times in room whether caring for [Resident Name] or roommate. Start Date: 11/12/2024

-Approach: Will move [Resident Name's] bed to opposite side of room for better viewing from staff in trial to decrease fall risk with increased observation of movement. Start Date: 9/16/2024

- Approach: Frequent rounds with change of shift, am/pm cares, meals, scheduled activities, routine toileting and NOC rounds. Ensure that feet have grippy socks in place. Start Date: 7/03/2024

-Approach: Resident is to wear gripper socks at all times. Will frequently remove. Staff to monitor and assist with replacement. Explain to [Resident Name] that foot coverings should be worn for safety and to prevent falls. Start Date: 7/03/2024

-Approach: Regular mattress as resident has had difficulty rising from bariatric scoop mattress. Start Date: 4/19/2024

-Approach: Gripper strips on floor in BRM (bedroom). Gripper strips next to bed on floor. Start Date: -12/01/2023

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0689 -Approach: Activities to offer 1:1 visits for 30-60 minutes daily and PRN (as needed) to decrease restlessness and provide increased comfort. Activities will engage resident at change of day/pm shift report Level of Harm - Minimal harm or times for increased supervision while staff is performing report and walking rounds. Start Date: 8/30/2023 potential for actual harm -Approach: Nursing staff to offer assistance with making bed Qshift (every shift). Start Date: 7/05/2023 Residents Affected - Few -Approach: Lamp at bedside to be turned on when in bed in the evening and night hours. Start Date: 4/28/2023

-Approach: WC brakes checked by maintenance. Remind [Resident Name] to lock brakes prior to transfers/standing. Start Date: 2/24/2023

-Approach: Keep shoes in w/c at bedside to promote wearing when she gets up. Start Date: 7/25/2021

-Approach: New personal phone placed in resident room. Start Date: 2/15/2021

-Approach: Educate and encourage use of proper footwear for all transfers/ambulation. Start Date: 11/13/2019

-Approach: Keep call light and frequently used items in reach. Keep walker within reach. Start Date: 12/20/2017

Resident R2's CNA (Certified Nursing Assistant) Basic Care Plan indicates in part: . Grip socks on at all times. (Does remove herself and needs monitoring to ensure placement) . Prompted toileting every 2-3 hours during day . Offer toileting every 1-2 hours at NOC . Lamp at bedside to be turned on when in bed in the evening and night hours .

On 3/27/25 at 8:39 AM, Surveyor observed Resident R2 at the table in the dining room eating breakfast. Resident R2 was wearing regular socks, not gripper socks, and no shoes.

On 3/27/25 at 10:02 AM, Surveyor observed Resident R2 resting in bed with her wheelchair next to the bed. The wheelchair did not have Dycem in place, there were no gripper strips on the floor by the bed, there were no shoes in the wheelchair at bedside, and there was no mat on the floor.

On 3/27/25 at 10:24 AM, Surveyor interviewed CNA U (Certified Nursing Assistant) and asked her what fall interventions were in place for Resident R2. CNA U indicated a lower bed, if she's up they try to have her at the nurse's station to keep an eye on her because she likes to self-transfer, and they offer her activities, snacks, and drinks.

On 3/27/25 at 10:31 AM, Surveyor interviewed LPN R (Licensed Practical Nurse) and asked her what fall interventions were in place for Resident R2. LPN R indicated a low bed, a lamp that gets turned on the bedside table, anti-lock roll back brakes on her wheelchair, pool noodles on her mattress, gripper socks on all the time and when she is up she often sits at the nurse's station with her so that she can monitor her better.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0689 On 3/27/25 at 10:46, Surveyor interviewed CNA N and asked her what fall interventions were in place for Resident R2. CNA N indicated a special wheelchair that won't roll back or tip back, she has a bed all the way to the floor Level of Harm - Minimal harm or with a floor mat, she's always to have gripper socks on, and rubber sticky stuff in her wheelchair. potential for actual harm

On 3/31/25 at 11:17 AM, Surveyor interviewed DON B (Director of Nursing) about Resident R2's multiple falls and fall Residents Affected - Few interventions. DON B stated that Resident R2 is in her own world and thinks she is capable of moving independently. DON B indicated that the IDT (Interdisciplinary Team) evaluates the root cause of each fall by investigating

the 5 whys of the fall, and that the physician and family are notified of each fall. DON B indicated that a new intervention is implemented after each fall, and that they have tried different wheelchairs, a Broda chair, and are currently on a waiting list for a different wheelchair for Resident R2. DON B stated that PT (physical therapy) was currently working with Resident R2 to increase her core muscles as one of the problems is that Resident R2 slides out of her wheelchair. DON B stated that they have Dycem in her wheelchair to prevent sliding and have also tried a waffle cushion. DON B stated that Resident R2 attempts to stand up independently and does not have good safety awareness. DON B stated they have increased toileting and rounding with Resident R2 and try to keep eyes on her. Surveyor asked DON B if she expected the care planned interventions for falls to be in place. DON B stated yes, she expected the care planned interventions to be followed. Surveyor shared with DON B her

observations and that a number of the care planned interventions were not being followed. Surveyor asked DON B how she monitors staff to ensure they are following care planned interventions. DON B indicated that

she does rounds every day in the morning and afternoon, but last week she was off on vacation so the ADON (Assistant Director of Nursing) should have been checking. DON B stated the ADON was new in her role, however, and probably was not aware that she should be monitoring this.

On 3/31/25 4:47 PM, Surveyor interviewed NHA A (Nursing Home Administrator) if she would expect the care planned interventions for falls for Resident R2 to be followed. NHA A stated that yes, she would expect care planned interventions to be followed, but that with Resident R2 it is sometimes difficult, because she will remove the Dycem from her wheelchair and hide it in the drawer, and that she is constantly taking off her gripper socks. NHA A stated that they have tried lots if interventions with her and that the are trying to keep her safe.

The facility failed to ensure that fall interventions were being followed for Resident R2, thereby failing to keep Resident R2 safe from repeated falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49434

Residents Affected - Few Based on interview and record review the facility did not ensure that a resident who enters the facility with an indwelling catheter receives appropriate treatment and services 1 of 1 residents (Resident R28) reviewed for indwelling catheters.

Resident R28 has an indwelling catheter, and has no physician order for the catheter, including its size and replacement schedule.

This is evidenced by:

The facility policy, entitled: Catheter Care, Urinary, dated 10/2022, states, in part: .Catheter Evaluation 1.

Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place .

The facility policy, entitled: Medication Orders, dated 11/2014, states, in part: . Supervision by a Physician . 2. A current list of orders must be maintained in the clinical record for each resident .

Resident R28 was admitted to the facility on [DATE REDACTED] with diagnosis that include, in part: heart failure, epilepsy (seizure disorder), history of cardiac arrest (heart stops beating), urinary incontinence, and obstructive and reflux uropathy (urinary tract becomes obstructed causing urine to flow backward into the kidneys).

Resident R28's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/27/25, indicates that Resident R28 has a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that she is cognitively intact. Section H indicates that Resident R28 is currently utilizing an indwelling catheter.

Resident R28's Comprehensive Care Plan states, in part:

Problem: Resident requires an indwelling urinary catheter R/T (related to) obstructive uropathy. Problem Start Date: 9/10/24.

Approach: Assess the drainage every shift and PRN (as needed). Record the amount. Observe for leakage. Start Date: 9/10/24.

Approach: Catheter, per MD order. Start Date: 9/10/24.

Approach: Change catheter per MD order. Start Date: 9/10/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0690 Approach: Follow Enhanced[sic] Barrier Precautions (EBP) r/t (related to) catheter use: 1) clean hands

before entering and when leaving room. 2) Wear gloves and a gown for high contact resident care activities. Level of Harm - Minimal harm or (Dressing, bathing, transfers, linen, changes, hygiene cares, changing briefs of toileting, catheter care) 3) potential for actual harm change gown and gloves for the care of more than one person. Start date: 9/10/24.

Residents Affected - Few Approach: Irrigate catheter only if an obstruction is suspected. Start Date: 9/10/24.

Approach: Provide catheter care BID (twice a day) and as needed. Start Date: 9/11/24.

Approach: Report signs of UTI (urinary tract infection) (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine). Start Date: 9/10/24.

Resident R28's Physician Orders state, in part:

Catheter care twice daily. Special Instructions: catheter care twice daily. Twice A Day. 06:30 - 14:30 (6:30 AM - 2:30 PM), 14:30 - 22:30 (2:30 PM - 10:30 PM). Start Date: 9/3/24. End Date: Open Ended.

Change drainage foley bag every 30 days. Special Instructions: Change drainage foley bag every 30 days. Once between the 3rd - 7th of the Month. Start Date: 9/3/24. End Date: Open Ended

Check catheter securement device three times a day and change every Monday. Special Instructions: Check catheter securement device three times a day and change every Monday. Once a Day on Mon (Monday). 14:30 - 22:30. Start Date: 9/3/24. End Date: Open Ended.

Flush Foley catheter with 60ml (milliters) of sterile normal saline. Special Instructions: to maintain patency. As Needed. PRN (As Needed) 1, PRN 2, PRN 3. (Indicates this can be done as needed up to 3 times a day). Start Date: 10/3/24. End Date: Open Ended.

Foley output Q (every) shift. Every Shift. day (day shift), pm (evening shift), noc (night shift). Start Date: 12/14/24. End Date: Open Ended.

Historical orders:

Change foley catheter 16 fr (French-indicates catheter size), 10 mL (milliters). Once - One Time. 22:00 (10:00 PM). Start Date: 3/11/25. End Date: 3/11/25.

Change foley catheter as it is occluded. Once - One Time. 17:30 (5:30 PM). Start Date: 3/23/25. End Date: 3/23/25. (Of note, this order specifically does not give a previous foley size or the size of the new foley to be place in the resident).

Of note: Resident R28 has no active foley catheter order indicating the size of the catheter or how much to put into the catheter balloon.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0690 On 3/31/24 at 11:41 AM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B what size foley catheter Resident R28 is supposed to have. DON B reviewed Resident R28's electronic medical record and indicated Level of Harm - Minimal harm or that she does not see the size in her care plan or in her physician orders. Surveyor asked DON B if there potential for actual harm should be an order for Resident R28's foley catheter and it's size. DON B states, yes.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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** 49434 potential for actual harm Based on observation, interview and record review, facility staff did not adequately assess and treat pain and Residents Affected - Few provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 (Resident R10) of 2 residents reviewed for pain management.

The facility failed to adequately assess and treat Resident R10's pain while providing wound care, causing Resident R10 to feel pain throughout the dressing change.

This is evidenced by:

The facility policy entitled, Pain Assessment and Management, dated 10/2022, states, in part: . 2. Pain Management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: . b. Recognizing the presence of pain; . f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary . Recognizing Pain . 2. Possible Behavioral Signs of Pain, including: a. negative verbalizations and vocalizations such as groaning, crying, screaming; b. facial expression such as grimacing, frowning, clenching of the jaw, etc.; . d. behavior such as resisting care . irritability .

Resident R10 was admitted to the facility on [DATE REDACTED], with diagnoses that include, in part: local infection of the subcutaneous tissue, cellulitis (infection of tissue beneath skin) of right lower limb, cellulitis of left lower limb, panic disorder, peripheral vascular disease, and systemic lupus erythematosus (immune system attacks healthy body tissues).

Resident R10's Quarterly Minimum Data Set (MDS), with a target date of 3/6/25, indicates Resident R10 has a BIMS score of 9 out of 15, indicating Resident R10 has moderate cognitive impairment. Section M indicates Resident R10 has 3 venous or arterial ulcers present along with moisture associated skin damage. Section J indicates Resident R10 occasionally has pain and her pain is rated 5 out of 10.

Resident R10's Comprehensive Care Plan states, in part:

Problem: Resident has open lower extremity venous ulcers R/T (related to) Peripheral vascular disease. RLE (Right Lower Extremity)- 12.5cm (centimeters) x 17 cm, L shin- 2.7 cm x 2.5 cm, L medial leg 1.2 cm x 2.0 cm, L posterior calf- 10.5 cm x 9.5 cm. Problem Start Date: 2/26/25.

Problem: Resident has a BLE (Bilateral Lower Extremity) venous ulcer. DX (Diagnosis): PVD (Peripheral Venous Disease). Problem Start Date: 12/9/24.

Approach: Give prn (as needed) morphine (opioid pain medication) one hour prior to BID (twice a day) lower leg dressing change. Approach Start Date: 3/11/25.

Approach: Prevent or treat pain during dressing changes and debridement by premedication as ordered. Approach Start Date: 12/9/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 Approach: Treatments as ordered. Approach Start Date: 12/9/24.

Level of Harm - Minimal harm or Problem: Resident has complaints of chronic pain R/T venous stasis ulcer to BLE, dx (diagnosis): arthritis. potential for actual harm Problem Start Date: 12/9/24.

Residents Affected - Few Approach: Administer medications as ordered and prn. Monitor and record effectiveness. Report adverse side effects. Alert MD (Medical Doctor) if meds (medications) are not effective. Approach Start Date: 12/9/24.

Approach: Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Approach Start Date: 12/9/24.

Approach: Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors, aggravating factors. Approach Start Date: 12/9/24.

Approach: Monitor and record any non-verbal signs of pain: (e.g., guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.). Approach Start Date: 12/9/24.

Approach: Use pain relief measure to promote relaxation and comfort. (repositioning, back rub, family visits, etc.) Monitor effectiveness. Utilize activities and conversation to help the resident focus on something other than pain or discomfort. Approach Start Date: 12/9/24.

Resident R10's Physician Orders state, in part:

Morphine (opioid pain medication) - Schedule II (Federal Controlled Substance Level) tablet immediate release; 15 mg; amt: 0.5 tab; oral. Special Instructions: give 1 hour prior to wound care BID prn. As Needed. PRN 1, PRN 2. Start Date: 12/31/24. End Date: Open Ended.

Cleanse LLE (Left Lower Extremity) with NS (Normal Saline), apply Santyl (removes dead tissue from wounds) to wound beds, add Calcium Alginate (absorbs drainage from wound) to wound beds, cover with Optilock (non-adherent, absorbent dressing) f/b (followed by) ABD (abdominal) pads (large, thick gauze dressing) and secure with Kerlix (gauze wrap). Special Instructions: Premedicate resident with prn Morphine 30-60 minutes prior to wound care. Twice A Day. 06:30 - 14:00 (6:30 AM - 2:00 PM), 14:30 - 22:30 (2:30 PM - 10:30). Start Date: 3/4/25. End Date: Open Ended.

Complete treatment to RLE (Right Lower Extremity): apply Optilock to ankle and cover with ABD (Abdominal Pad) and wrap with Kerlix. Change twice a day[sic] and prn. Twice A Day. 08:00 - 15:00 (8:00 AM - 3:00 PM), 15:00 - 22:30 (3:00 PM - 10:30 PM). Start Date: 3/25/25. End Date: Open Ended.

Give prn morphine one hour prior to BID (twice a day) lower leg dressing change. Special Instructions: sign out med in the prn list. Twice A Day. 06:30 - 14:00. 14:30 - 21:00 (9:00 PM). Start Date: 12/24/24. End Date: Open Ended.

Of note: Resident R10 had other medications available as needed which were tylenol, cyclobenzaprine, lidocaine and tramadol.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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

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

F 0697 On 3/26/25 at 10:46 AM, Surveyors observed LPN S (Licensed Practical Nurse) complete wound treatment for Resident R10. During the wound treatment, after the old bandages were removed, Surveyor observed macerated Level of Harm - Minimal harm or (occurs when skin is in contact with moisture for too long and is often a sign of improper wound care) skin on potential for actual harm the right leg from below Resident R10's knee to her ankle, around the entire circumference of her lower leg. LPN S proceeded to wet gauze with normal saline (water and 0.9% salt mixture) then dab and wipe Resident R10's leg. As Residents Affected - Few this occurred, Resident R10 started crying and saying, That's enough! repeatedly. LPN S replied, I know I just want to get it all. Surveyor asked LPN S about the leg wound. LPN S indicated Resident R10's right lower leg wound started as a fluid-filled blister below her knee than became more and more macerated from the fluid-soaked dressings. Surveyor observed purulent (pus-like fluid) drainage and macerated skin on the left lower extremity. Surveyor also noted a large wound on the posterior (back of) left lower extremity. Slough (necrotic tissue that accumulates on the surface of the wound) present in this wound. LPN S began the wound treatment on this leg by appearing to peel off skin. Resident began yelling Ow! Ow! and wincing. LPN S replied I'm sorry, we got to get all the bad stuff off. Resident R10 clenching teeth throughout process. LPN S instructed Resident R10 to take a deep breath. Resident continued to cry out and her breathing was shallow. LPN S continued

the wound treatment as ordered. Resident R10 continued to cry out please!. LPN S replied, I just need to clean it. LPN S continued the wound treatment by applying the Santyl directly to the wound as ordered. Resident R10 continued wincing and crying.

On 3/26/25 at 11:46 AM, Surveyor interviewed LPN S. Surveyor asked LPN S when she premedicated Resident R10. LPN S indicate she gave Resident R10 morphine at about 9:57 AM. Surveyor asked LPN S about LPN S mentioning Resident R10 was more uncomfortable today. LPN S indicated she believed Resident R10 had anxiety related to her phone call with her family prior to her wound care treatment. Surveyor asked LPN S if she has ever stopped a wound treatment due to a resident being in pain or uncomfortable. LPN S indicates she has not, but slow, deep breaths usually work for Resident R10. Surveyor asked LPN S if she should have stopped Resident R10's treatment due to her crying out in pain. LPN S indicates, yeah, maybe I should have stopped. Surveyor asked LPN S if she has ever refused treatment due to pain. LPN S indicates Resident R10 used to refuse due to pain but not so much anymore.

On 3/31/25 at 2:56 PM, Surveyor stopped by Resident R10's room to interview her about her pain with wound treatments. At this time, Resident R28, Resident R10's roommate stopped Surveyor to let her know that Resident R10 screams in pain

during her dressing changes.

On 3/31/25 at 3:23 PM, Surveyor interviewed DON B and ADON HH. Surveyor asked DON B if it is ordered, should staff premedicate residents prior to wound care. DON B indicates yes, unless the resident refuses. Surveyor asked DON B if a resident is yelling out in pain and displaying visible signs of discomfort, what should the nurse do. DON B indicates the nurse should stop and reassess the pain. Surveyor asked ADON HH if she usually participates in Resident R10's wound care. ADON HH indicates she completes wound treatments with the wound Advanced Practice Nurse Prescriber. Surveyor asked ADON HH what Resident R10's usual demeanor is with wound treatments. ADON HH indicates Resident R10 has good and bad days and that it usually depends on what is going on in her life, specifically family dynamics. ADON HH also indicates Resident R10 has high anxiety days where very few interventions will be effective. Surveyor asked ADON HH what interventions are effective on

the high anxiety days. ADON HH indicates lorazepam generally works best on those days. Surveyor advised ADON HH of the observations of pain made during wound treatment and asked what ADON HH would have done had she been completing the wound treatment. ADON HH indicated she would have stopped the treatment and evaluated Resident R10's pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 39849 potential for actual harm Based on observation, interview, and record review, the facility did not ensure that each resident receives Residents Affected - Few food and drink that is palatable and at a safe and appetizing temperature for 1 of 17 sampled Residents (Resident R15) and 1 of 1 test trays.

Resident R15 voiced a concern about hot foods being served cold.

Surveyor received a breakfast test tray and the food temperatures were not palatable.

Evidenced by:

The undated facility policy, Food Temperatures, indicates, in part: Policy: Food temperatures shall be tested & recorded prior to meal service by food service employee. Purpose: To ensure that food is held at safe temperatures to prevent food borne illness and to ensure palatable food temperatures .

On 3/25/25 at 2:00 PM, Surveyors interviewed Resident R15 as part of the initial screening process. Resident R15 indicated that the scrambled eggs and vegetables are sometimes cold. Resident R15 indicated the food is cold around 3 times a week and that she stopped eating scrambled eggs because of it.

On 3/26/25 at 3:50 PM Surveyors interviewed CNA M (Certified Nursing Assistant) and asked if residents have brought up concerns regarding cold food. CNA M indicated staff will be passing out trays and the kitchen will want to be quick and they will prep the last few trays and leave them for us to get. CNA M indicated that she may be running a tray to a room and by the time she gets back the trays are sitting there and then it can be cold. CNA M provided the following example: If she drops off a tray and then that resident wants mayo and then I have to go get the mayo and go back, then the tray the kitchen has scooped up is sitting there getting cold. Surveyors asked CNA if she felt this was something she should have reported. CNA M indicated, probably, now that I'm saying it out loud.

50285

Example 2:

On 3/26/25 at 8:32 AM, Surveyor received a test tray after both dining rooms and all hall trays had been served on the 3rd floor. (Of note, the plates for the room trays are set directly onto the tray and are covered by a plastic cover). Surveyor took the temperatures of the food that was served, including scrambled eggs, sausage links, oatmeal, milk and coffee. Surveyor noted that several of the items were in the temperature danger zone, including the scrambled eggs (temperature of 115.3 degrees F (Fahrenheit), which also tasted cold), sausage links (temperature of 91.6 degrees F), and milk (temperature of 45.4 degrees F).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0804 On 3/26/25 at 8:54 AM, Surveyor interviewed DM E (Dietary Manager). Surveyor asked DM E if she would expect the food that is served to be at the desired temperatures. DM E stated that the hot foods are expected Level of Harm - Minimal harm or to be 165 degrees F when they are brought up from the kitchen and placed in the steam table. Surveyor potential for actual harm asked DM E if the eggs were served at a safe temperature at 115 degrees F. DM E replied she would have to look at the palatability of the eggs. Surveyor asked DM E about the safety of milk served at 45 degrees F. Residents Affected - Few DM E stated that milk should be 41 degrees F or lower and that they had it in a tray of ice to keep it cold.

The facility failed to ensure that each resident received food and drink that is palatable and at a safe and appetizing temperature.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50285

Residents Affected - Many Based on observation, interview and record review, the facility did not distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 45 residents.

Facility staff were observed touching multiple items in the kitchenette while serving and handling food without changing gloves or performing proper hand hygiene.

Cook D was observed dishing up lunch from the steam table with gloves on, stepping away from the steam table, touching other surfaces in the kitchenette, returning to the steam table for meal plating and touching ready to eat foods while wearing the same pair of gloves.

Surveyor observed visible build on and debris in two ovens.

Surveyor observed a visible white substance on inside and outside of a steam kettle.

Surveyor observed a visible white substance on the outside of an ice machine.

Surveyors observed a refrigerator containing resident food and drink in a kitchenette on 2nd floor without daily temperature monitoring being completed.

Evidenced by:

Facility policy, entitled Handwashing/Hand Hygiene, dated 2021 with Revision Date of October 2023, includes in part, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene: 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for Hand Hygiene: 1. Hand hygiene is indicated . g. immediately after glove removal .5. The use of gloves does not replace hand washing/hand hygiene .

Example 1:

On 3/26/25 at 7:44 AM, Surveyor observed [NAME] D wearing disposable gloves during meal service. Surveyor observed [NAME] D dishing up food at the steam table, stepping away from the steam table, opening the refrigerator door to remove a can of Sun Drop for a resident, then touching bread to make toast for the breakfast service. [NAME] D touched the bread, the toast lever, and the toast coming out of the toaster without changing gloves or performing hand hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0812 On 3/26/25 at 8:36 AM, Surveyor interviewed [NAME] D who indicated they had received annual education about hand hygiene and food safety, as well as periodic refresher training's throughout the year. Surveyor Level of Harm - Minimal harm or asked [NAME] D when hand hygiene should be performed. [NAME] D stated before entering the kitchenette potential for actual harm to start meal service. Surveyor asked [NAME] D if gloves should be changed, and hand hygiene performed

before touching ready to eat foods. [NAME] D replied yes, you should wash hands or change gloves before Residents Affected - Many touching ready to eat foods. Surveyor asked [NAME] D if she had missed an opportunity for hand hygiene

during meal service. [NAME] D replied no, that she had not left the kitchenette at all during meal service. Surveyor asked how often the common surfaces in the kitchenette were sanitized such as door handles. [NAME] D stated they are cleaned daily. Surveyor asked [NAME] D if cross contamination could occur if the kitchen staff were touching common surfaces and then touching food such as bread to make toast without changing gloves or performing hand hygiene. [NAME] D replied yes.

On 3/26/25 at 8:44 AM, Surveyor interviewed DM E (Dietary Manager). Surveyor asked DM E when she would expect staff to perform hand hygiene or change gloves. DM E indicated that she would expect staff to perform hand hygiene before they start to dish up food, anytime they leave the kitchenette, or if they are touching food in between. Surveyor asked DM E if staff should change gloves or perform hand hygiene

before touching ready to eat items such as bread. DM E stated that if they were wearing gloves no because there was no bare hand contact. Surveyor asked DM E should the staff change gloves or perform hand hygiene if they had touched surfaces such as door handles and before touching bread. DM E stated yes, if

they had touched any door handles or surfaces then staff need to change gloves before they touch food again.

Facility staff failed to perform proper hand hygiene, causing a risk for cross contamination by touching multiple surface areas in the kitchen then touching ready to eat foods.

49434

Example 2:

On 3/24/25 at 12:15, Surveyor was observing dining on the 3rd floor. Surveyor observed a gallon of milk placed on a cart, not on ice or device to keep the milk at a safe temperature.

On 3/24/25 at 12:42, Surveyor observed staff start to return the milk to a refrigerator. Surveyor asked DM E to take the temperature of the milk at that point. DM E showed Surveyor the thermometer, which showed 44F (Fahrenheit). Surveyor asked DM E what temperature the milk should be at. DM E indicates milk should be at 40F or below. DM E then indicated she would be disposing of the milk as it had reached an unsafe temperature.

The facility did not distribute and serve food in accordance with professional standards for food service safety.

39849

Example 3

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0812 The undated facility policy, Department of Dietary Infection Control: Steam Kettle, indicates, in part: Policy:

The steam kettle shall be cleaned after each period of use by designated Dietary personnel . Level of Harm - Minimal harm or potential for actual harm The facility policy, Department of Dietary Infection Control: Convection Oven, without an implementation or revision date, indicates, in part: Policy: The convection oven shall be cleaned monthly or if a spill by the cook Residents Affected - Many .

On 3/24/25 at 8:49 AM, Surveyor completed the initial kitchen tour with DM E (Dietary Manager). Surveyor observed debris on the inside of the baking convection oven and the cooks convection oven. Both ovens were observed to have dried matter on the front portion of the ovens under where the doors close. DM E indicated that she felt these ovens needed to be cleaned and that they are supposed to be cleaned monthly.

Surveyor observed a white substance on the inside and outside of the steam kettle and on the floor by the steam kettle. DM E Indicated the steam kettle should be cleaned daily when they use it. DM E indicated she felt if it was being cleaned at that frequency it would not have this much build up and needed to be cleaned.

Surveyor observed the ice machine (located by the clean dish area) to have a white substance build up on

the right outer side of the machine. DM E indicated that any build up should be cleaned by staff between maintenance cleanings and that this needed to be cleaned. DM E indicated there is not a log for when the ice machine should be cleaned.

On 3/27/25 at 2:22 PM Surveyors interviewed DM E and requested cleaning policies for the ovens and steam kettle. DM E indicated she had a cleaning schedule that indicates which person should be doing which cleaning.

Of note, cleaning logs that were provided did not list ovens or the steam kettle.

Example 4

On 3/24/25 at 12:20 PM, Surveyors observed clip boards on the 2nd floor refrigerator in the kitchenette nearest the elevators. A sign observed on the refrigerator indicates it is for resident items. The March 2025 Fridge/Freezer temperature log has temperatures documented on March 1st and on March 18th - 23rd. The February 2025 Fridge/Freezer log has temperatures documented for February 5th, 6th, and 10th.

On 3/24/25 at 1:51 PM, Surveyors interviewed CNA N who indicated she thought the refrigerator was only being used for things residents bring in, like soda. Surveyors observed the inside of the refrigerator/freezer with CNA N. CNA N confirmed the fast food bag and an unopened bottle of soda noted in the refrigerator belong to residents. CNA N indicated the kitchen staff is responsible for monitoring and documenting temperatures of the fridge and freezer.

On 3/26/25 at 4:38 PM, Surveyors interviewed NHA A (Nursing Home Administrator) and reviewed the temperature logs referenced above. NHA A indicated she would expect the temperature log to be filled out completely for all dates.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 0812 On 3/27/25 at 2:22 PM Surveyor reviewed the temperature logs with DM E who indicated the temperatures should have been monitored by the kitchen staff and recorded. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 61 525241

F-F610.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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** 50285 potential for actual harm Based on interview and record review, the facility did not ensure that in response to allegations of abuse, Residents Affected - Some neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 3 of 3 sampled residents (Resident R3, Resident R6, Resident R46) and 2 of 3 supplemental residents (Resident R19, Resident R18) reviewed for abuse investigations.

On 10/8/24 the facility became aware that Resident R18 had been left in her wheelchair all night without being changed or assisted to bed. The facility completed a grievance form but did not complete a thorough investigation.

On 12/15/24 the facility became aware that Resident R19 had her call light on all night, but that staff had shut her door and not assisted her to get changed from her wet brief. The facility completed a grievance form but did not complete a thorough investigation.

On 12/16/24 the facility became aware that Resident R6 had received an enema then was left in his stool for hours without being changed and cleaned up by staff. The facility completed a grievance form but did not complete

a thorough investigation.

On 11/13/24 the facility became aware that Resident R3 stated he had not been changed and then a CNA (Certified Nursing Assistant) entered his room and waved his wet brief in his face. The facility completed a grievance form but did not complete a thorough investigation.

The facility became aware of an allegation of abuse on 11/25/24 during Resident R6's care conference by FM II and

the facility did not investigate the allegation.

During a NOC (night) shift on 11/28/24 to 11/29/24, CNA H (Certified Nursing Assistant) heard Resident R46 calling for help. CNA H (Certified Nursing Assistant) observed Resident R46 to be bright red and shaking with fresh blood on his right forearm (from a skin tear) and bedding. Resident R46 stated, CNA F (Certified Nursing Assistant) and LPN G (Licensed Practical Nurse), both agency staff, wouldn't let him get up and held his hands down. This allegation was not thoroughly investigated and the facility did not provide training to staff regarding physically restraining residents to ensure this does not occur again.

Evidenced by:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 Facility policy entitled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001, with Revision Date of September 2023, states, in part: Policy Statement: All reports of resident abuse . Level of Harm - Minimal harm or neglect, exploitation, or theft . are to be reported to local, state, and federal agencies . and thoroughly potential for actual harm investigated by facility management. Findings of all investigations are documented and reported . Reporting Allegations to the Administrator and Authorities: . 6. Upon receiving any allegations of abuse, neglect . the Residents Affected - Some administrator is responsible for determining what actions (if any) are needed for the protection of the residents . Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations . 7. The individual conduction the investigation as a minimum: a. reviews the documentation and evidence; reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents' d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly .

Example 1:

Resident R18 was admitted to the facility on [DATE REDACTED]. Resident R18's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/25, indicates Resident R18 has a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicating Resident R18 is cognitively intact.

Resident R18's Basic CNA (Certified Nursing Assistant) Care Plan, dated 7/5/24 states, in part: Transfers: EZ Stand (a stand assist device) with assist of 2, use Hoyer (a mobile lift service) with 2 assist on PM (evening) shift. Mobility: WC (wheelchair) for mobility. Encourage to propel short distances. Staff to assist as needed. Dressing: Extensive assist of 1 with UB (upper body) dressing and hygiene. Assist of 1 to complete LB (lower body) dressing and hygiene . Prompted toileting with AM/PM (morning/evening) cares, rounds and PRN (as needed).

On 10/28/24, the facility became aware of an allegation of abuse involving Resident R18. A Grievance Form was completed that indicates the following, Nature of the Concern: [Resident Name] states that nobody came to check on her all night. She said that nobody put her in her bed. [Resident Name] was very distraught, tired, wet and wanted to get in bed. Witness account by HM O (Housekeeping Manager) states: I arrived on the 3rd floor at approximately 4:10 AM. [Resident Name] was in her wheelchair in the doorway of her room and

she was crying. She told me that nobody put her to bed or checked on her all night. She was very distraught and asked what she did wrong because they wouldn't help her. She said she was tired and sitting in her pee and needed to get to bed. I found the nurse, she said she was too busy to notice she was never put to bed. I got the 2 CNA's and they said they had never seen [Resident Name] before. I told the CNA's to get her cleaned up and in bed. Investigation: Resident stated she was not put into bed until very early this morning. Resident upset that she was left up late, missed breakfast, and missed some activities. Resident was happy that HM O helped her and got staff to get her into bed. Resolution: Education and more frequent rounds.

Review and update care plans. Follow-up: No further concerns. The Grievance Form was signed by NHA A (Nursing Home Administrator).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 3/31/25 at 2:49 PM, Surveyor interviewed Resident R18 about the incident that happened on 10/28/24. Resident R18 remembered the incident and stated that nobody put her into bed, and nobody checked on her all night. Resident R18 Level of Harm - Minimal harm or stated she was tired and scared because she never saw a CNA all night. potential for actual harm

The facility did not follow their abuse policy to complete a thorough investigation, as no other residents or Residents Affected - Some staff members were interviewed to identify any further abuse or neglect.

Example 2:

Resident R19 was admitted to the facility on [DATE REDACTED]. Resident R19's most recent MDS, with an ARD of 1/3/25, indicates Resident R19 has a BIMS score of 10 out of 15, indicating Resident R19 has mild cognitive impairment.

Resident R19's Basic CNA Care Plan, dated 1/15/25 states, in part: Transfers: 1 assist and 2 WW (wheeled walker). Mobility: Ambulates with 1 assist and 2WW. Dressing: Assist of 1 for UB/LB (upper body/lower body) cares. Toileting: Prompted toileting assist every 2-3 hours.

On 12/15/24, the facility became aware of an allegation of abuse involving Resident R19. A Grievance Form was completed that indicates the following, Nature of the Concern: Resident states that she had her call light on all night. She states when the CNA came in, she told her that she was soaked in pee all the way up her back. Resident states that the CNA left the room and shut the door without changing her. Resident states she was scared because the door was shut, and she was angry because she was left to lay in her pee all night. Investigation: Resident upset her needs were not met and her door was shut. Resident did not know the name of the staff member involved and could only tell this writer it was a female staff member. Resolution: Education to staff on rounding and all resident doors are to be open unless cares are being completed. Follow-up: No further concerns expressed by the resident at this time. The Grievance Form was signed by NHA A on 12/17/24.

On 3/31/25 at 2:40 PM, Surveyor interviewed Resident R19 about the incident that happened on 12/15/24. Resident R19 remembered the incident and stated that she had her call light on all night and was left in pee all night. Resident R19 stated the CNA closed the door and she felt afraid. Resident R19 said it made her feel terrible, that she was crying, and that she was overwhelmed and angry that they weren't taking care of her, and she had to lay in pee like that all night.

The facility did not follow their abuse policy to complete a thorough investigation, as no other residents or staff members were interviewed to identify any further abuse or neglect.

Example 3:

Resident R6 was admitted to the facility on [DATE REDACTED]. Resident R6's most recent MDS, with an ARD of 3/12/25, indicates Resident R6 has

a BIMS of 15 out of 15, indicating Resident R6 is cognitively intact.

Resident R6's Basic CNA Care Plan, dated 9/13/24 states, in part: Transfers: 2 assist and Hoyer. Mobility: Propels self

in WC. Dressing and Toileting: Extensive assist with hygiene and dressing. Supra pubic catheter. Incontinent of bowel. Provide incontinence care after each incontinent episode.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 12/16/24 the facility became aware of an allegation of abuse involving Resident R6. A Grievance Form was completed that indicated the following, Nature of the Concern: Resident was given a suppository or enema Level of Harm - Minimal harm or and no one came back in to check on him. Resident states he had a BM (bowel movement) and was not potential for actual harm changed until the AM shift when the aide came in to get him ready for breakfast. Investigation: Resident states after receiving an enema he was not checked on or changed until AM shift came in to get him ready Residents Affected - Some for breakfast. Resolution: Resident care plan updated. Follow-up: No further concerns from resident at this time. The Grievance Form was signed by NHA A on 12/20/24.

On 3/31/25 at 2:33 PM, Surveyor interviewed Resident R6 about the incident that happened on 12/16/24. Resident R6 remembered the incident and stated that he had an enema and no one came back in to check or change him. Resident R6 stated that he had a BM and stayed in it all night, and that he wasn't cleaned up for several hours until the next morning.

The facility did not follow their abuse policy to complete a thorough investigation, as no other residents or staff members were interviewed to identify any further abuse or neglect.

Example 4:

Resident R3 was admitted to the facility on [DATE REDACTED]. Resident R3's most recent MDS, with an ARD of 1/2/25, indicates Resident R3 has a BIMS of 11 out of 15, indicating Resident R3 has a mild cognitive impairment.

Resident R3's diagnoses include, in part: Type 2 diabetes mellitus with diabetic chronic kidney disease, Chronic Obstructive Pulmonary Disease (COPD), Constipation, Essential hypertension, Pain unspecified, Generalized anxiety disorder, Unspecified dementia with anxiety, Depression unspecified, Low back pain, Personal history of neoplasm of the skin, Chronic kidney disease stage 3, Functional urinary incontinence, Chronic instability of left knee, Pain in left knee, Unspecified congestive heart failure.

Resident R3's Basic CNA Care Plan, dated 3/16/25 states, in part: Transfers: Hoyer transfer with 2 assist. Mobility: WC for mobility staff to assist. Toileting: Has agreed to use bedpan/urinal for toileting needs. Offer assistance every 2-3 hours and PRN providing peri-care and assist with clothing management. Dressing: Minimum assist of 1 for UB (upper body) and Max assist for LB (lower body) and with toileting cares.

On 11/13/24 the facility became aware of an allegation of abuse involving Resident R3. A Grievance Form was completed that indicated the following, Nature of the Concern: Resident states a group of 3 girls turned him

in bed but did not change his brief. Resident states that he called a nurse down to his room and told the nurse he had not been changed. A CNA came back to his room and put the wet brief in his face, per resident. Investigation: Resident states he was helped in bed by 3 girls but his brief was not changed. Resident called the nurse down to his room and told her he had not been changed, per resident. A CNA came in and put the wet brief in his face and said, Look! I wouldn't not change you. Resident was asked to describe the CNA. Resident stated she ha a lot of hair on top of her head. Resolution: Agency CNA DNR (Do Not Return). Follow-up: No further concerns from resident. The Grievance Form was signed by NHA A on 11/15/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 61 525241 Department of Health & Human Services Printed: 08/31/2025 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 525241 B. Wing 03/31/2025

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

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

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 3/31/25 at 3:56 PM, Surveyor interviewed SW C (Social Worker) who is the facility Grievance Officer. SW C stated that she had only been working at the facility since January and had no knowledge of the events Level of Harm - Minimal harm or involving Resident R18, Resident R19, Resident R6, or Resident R3. Surveyor asked SW C to read the grievance forms for these incidents. SW C potential for actual harm read the forms and stated that in her opinion she would consider these incidents as allegations of potential abuse, and she would have wanted to investigate them if she was the Grievance Officer at that time. SW C Residents Affected - Some states that if a resident reports a grievance of any kind, she starts an investigation by speaking to the resident, the staff on the floor, and the previous shift. Surveyor asked SW C if she follows up with the resident after the investigation. SW C stated yes, she follows up with the resident after she completes her investigation and gives them a status update as well as what the resolution is. SW C ensures that the resident is satisfied with that solution.

On 3/31/25 at 4:24 PM, Surveyor interviewed NHA A about these grievance forms and these incidents. Surveyor asked NHA to read the grievance forms and if they would be considered allegations of abuse. NHA

A replied yes, they would be potential neglect allegations. Surveyor asked NHA A if they were reports of potential abuse, had they been thoroughly investigated. NHA A replied that for most of them they followed through on them, but they didn't have a file or documentation on them. NHA A stated that they should have been reported and investigated. NHA A stated that she has learned the hard way to take ownership of abuse allegations and ensure that everything gets done properly.

The facility did not follow their abuse policy to complete a thorough investigation, as no other residents or staff members were interviewed to identify any further abuse or neglect.

Cross Reference