Elroy Health Services

F-F609) or the facility must clearly document the rationale for not reporting.

The facility failed to recognize and report a resident-to-resident altercation, despite several staff members having knowledge of the incident. The facility failed to recognize a resident's verbally aggressive behaviors and negative interactions with other residents as abuse and failed to report this incident to the state agency within the appropriate timeframes.

Cross Reference:

F-F610.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 44552

Residents Affected - Many Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 68 residents who reside at the facility.

Surveyor observed dietary aide without a beard restraint in the kitchen.

Surveyor observed garbage cans near the food prep area without lids.

Surveyor observed spilled food or drink in the walk-in fridge.

Evidenced by:

The facility policy, Employee Sanitary Practices- Food and Nutrition Services, dated, 7/27/22, states, in part; . All food and nutrition services employees will practice good personal hygiene and safe food handling procedures .1. Wear hair restraints (hairnet, beard restraint) to prevent hair from contacting exposed food .

On 2/16/25 at 9:45 AM, Dietary Manager K (DM) and Surveyor toured the kitchen. Surveyor observed Dietary Aide L (DA) in the kitchen not wearing a beard restraint. Surveyor observed garbage cans near the food prep area without lids. Surveyor observed yellow substance spilled in the walk-in refrigerator. DM K indicated she will ask staff to clean up the spill and it most likely was eggs.

On 2/19/25 at 1:20 PM, Nursing Home Administrator A (NHA) indicated he would expect staff to wear a beard restraint when in the kitchen and when handling food. NHA A indicated understanding with the spilled food and need for lids on garbage cans near food and food prep area.

The facility failed to maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 49436 potential for actual harm Based on observations, interview, and record review the facility did not maintain an infection prevention and Residents Affected - Many control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 68 residents (R) residing in the facility.

The facility's outbreak that started in October 2024 was resolved too early.

Facility staff were unaware of their current outbreak and were not following proper source control during the outbreak.

Staff surveillance was not complete for staff illnesses and staff returned to work too early from illnesses.

This is evidenced by:

The facility's policy titled Infection Prevention and Control Program, dated 7/23/24, states in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. The designated Infection Preventionist is responsible for oversight of the program and serves as a leader to our staff on infectious disease, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all resident, staff .based upon a facility assessment and accepted national standards. The infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility . All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.

The facility's policy titled Infection Outbreak Response and Investigation, dated 2/26/23, states in part: Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. If a condition is rare or has serious health implications, an outbreak may involve only one case. The following triggers shall prompt an investigation as to whether an outbreak exists: .A single case of a rare or serious infection (i.e. COVID-19). Implementation of infection control measures: .Symptomatic employees will be screened by the Infection Preventionist, or designee . Transmission-based precautions will be implemented as indicated for

the particular organism. Staff should be educated on the mode of transmission of the organism, symptoms of infection and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved.

Example 1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0880 Facility document titled Covid Outbreak Time Log 10/1/24 to 11/17/24, states in part: On 10/2/24, the facility initiated a COVID outbreak. On 11/2/24, Resident R1 tested positive for COVID. On 11/17/24, the facility ended their Level of Harm - Minimal harm or outbreak status and discontinued universal masking. potential for actual harm According to dhs.wisconsin.gov, respiratory outbreaks can be closed after two incubation periods have Residents Affected - Many passed with no new cases being identified. For COVID-19 outbreaks, this is 28 days .

Of note, the facility ended their outbreak on day 15.

Example 2

On 2/16/24 at 9:20 AM, Surveyors entered the facility. Posted on the front entrance door was a sign titled Attention Visitors. The sign states in part: Attention Visitors We are currently experiencing a COVID outbreak . If you choose to visit during this outbreak, please review the following: .Facemasks should be worn at all times during your visit.

On 2/16/25 at 9:30 AM, Surveyor observed DA L (Dietary Aide) delivering a drink cart on the hallway without

a mask on.

On 2/16/25 at 12:54 PM, Surveyor interviewed DA L regarding the COVID outbreak. During the interview, Surveyor observed DA L did have a mask on. DA L was not wearing the mask appropriately as the mask was below his nose during the interview. DA L indicated he was not aware the facility was in outbreak and that is why he had not been wearing a mask earlier. Surveyor asked DA L if he had education on the correct way to wear a mask and DA L indicated he was aware of the correct way to wear a mask. Surveyor asked DA L if he was wearing the mask correctly and DA L indicated he was not wearing the mask correctly.

On 2/16/25 at 9:32 AM, Surveyor observed CNA O (Certified Nursing Assistant) sitting in the center hub of

the facility without a mask on.

On 2/16/25 at 12:54 PM, Surveyor interviewed CNA O regarding the COVID outbreak. CNA O indicated she should have been wearing a mask earlier but was not. Surveyor observed CNA O during the interview wearing her mask correctly.

On 2/16/25 at 11:10 AM, Surveyor interviewed LPN N (Licensed Practical Nurse) regarding COVID outbreak. LPN N indicated the facility was not in outbreak and staff were wearing mask as a precaution.

On 2/17/25 at 12:55 PM, Surveyor observed RN P (Registered Nurse) standing in the hallway wearing her mask below her chin while talking to visitors. Surveyor interviewed RN P regarding the correct way to wear a mask. RN P indicated she was not wearing the mask correctly. RN P indicated she believed there had only been one staff member who tested positive for COVID, and it was past 10 days so she is unsure if the facility was still in outbreak.

On 2/16/25 at 12:51 PM, DON B (Director of Nursing) indicated the facility had been in COVID outbreak status since 2/4/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0880 On 2/17/25 at 8:23 AM, Surveyor observed DA Q walk into the dining room from an outside entrance and walk into the kitchen not wearing a mask. When surveyor went to interview DA Q, she had already left the Level of Harm - Minimal harm or facility. potential for actual harm

On 2/17/25 at 8:25 AM, Surveyor observed PC R (Pest Control Contractor) walk out of the kitchen, through Residents Affected - Many the dining room where residents were eating breakfast and to the center hub of the facility. PC R was not wearing a mask. Surveyor observed PC R speaking with NHA A (Nursing Home Administrator). Surveyor interviewed PC R regarding not wearing a mask. PC R indicated he was not aware there was a mask mandate in the facility. PC R indicated he did not notice the sign on the front door indicating the facility was

in a COVID outbreak. PC R indicated no staff member told him the facility was in outbreak. PC R indicated no staff member asked him to put on a mask.

On 2/17/25 at 8:25 AM, Surveyor interviewed NHA A regarding contractors wearing a mask while in the facility. NHA A indicated the facility recommends contractors wear a mask. NHA A indicated there is a sign at

the front door stating the facility is in a COVID outbreak.

On 2/18/25 at 12:30 PM, Surveyor interviewed DON B regarding the COVID outbreak. DON B indicated staff should be aware of the outbreak and should wear their mask correctly.

Example 3

Surveyor reviewed the facility's staff line list for November 2024, December 2024, and January 2025.

November 2024 staff line list states in part:

11/19/24 LPN EE (licensed practical nurse) called in with symptoms of fatigue, nausea, emesis, and diarrhea. Return to work date of 11/22/24. Of note, there is no date symptoms resolved.

December 2024 staff line list states in part:

12/7/24 HA FF (Hospitality Aide) called in with symptoms of headache, nausea, and emesis. Return to work date of 12/8/24. Of note, there is no date symptoms resolved, and the return-to-work date is 24 hours after GI (gastrointestinal) symptoms.

12/10/24 CNA GG called in with symptoms of nausea, emesis, and diarrhea. Return to work date of 12/11/24. Of note, there is no date symptoms resolved, and the return-to-work date is 24 hours after GI symptoms.

12/16/24 UC J (Unit Clerk) called in with symptoms of myalgia (muscle pain), headache, and sore throat. Of note, there are no testing results listed, and no date symptoms resolved.

12/20/24 HA FF called in with symptoms of emesis. Return to work date of 12/21/24. Of note, there is no date symptoms resolved, and the return-to-work date is 24 hours after GI symptoms.

12/23/24 HA HH called in with symptoms of nausea and emesis. Of note, there is no date symptoms resolved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0880 January 2025 staff line list states in part:

Level of Harm - Minimal harm or 1/2/25 HA FF called in with symptoms of fever, emesis, and diarrhea. Of note, there is no date symptoms potential for actual harm resolved.

Residents Affected - Many 1/2/25 RN I called in with symptoms of myalgia, headache, sore throat, cough and diarrhea. Of note, there is not testing results listed, and no date symptoms resolved.

1/5/25 CNA DD called in with symptoms of emesis and diarrhea. Of note, there is no date symptoms resolved.

1/7/25 MN II (Maintenance) called in. Return to work date of 1/8/25. Of note, there are no symptoms listed.

1/21/25 HO JJ (Housekeeper) called in with symptoms of fever, headache, sore throat, rhinorrhea (runny nose), and itching. Testing results listed Influenza. Comments section states return to work 1/25/25 if fever free without medication and symptoms improve. Of note, there is no date symptoms resolved.

1/28/25 CNA KK call in with symptom of sore throat. Return to work date 1/7/25 [sic]. Of note, there is no date symptoms resolved.

1/28/25 CNA LL called in with symptoms of nausea, emesis, and diarrhea. Of note, there is no date symptoms resolved.

On 2/18/25 at 12:30 PM, Surveyor interviewed IP S (Infection Preventionist) regarding staff surveillance. DON B was also present for the interview. IP S indicated staff should remain out of the facility if they have GI symptoms for 48 hours after symptoms have resolved. IP S indicated without completing the section of when symptoms resolved it is hard to determine if staff returned to work too early. IP S indicated HA FF and CNA GG returned to work too early. IP S indicated COVID testing should be completed if staff have symptoms of COVID and it should be documented on the line listing. IP S indicated RN I and UC J should have had testing completed. IP S indicated MN II should have had documented symptoms when he called in. IP S indicated the staff line listing should be filled out completely and was not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 525452

F-F686

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50285 potential for actual harm Based on observation, interview, and record review, the facility did not ensure a resident who displays or is Residents Affected - Few diagnosed with dementia receives the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 2 residents (Resident R50) reviewed for dementia care out of a total sample of 20 residents.

Resident R50 has a diagnosis of dementia. Resident R50 has a history of exhibiting verbally aggressive and socially inappropriate/disruptive behavior towards staff and other residents. The facility staff did not provide person-centered services to maintain Resident R50's highest practicable physical, mental, and psychosocial well-being.

Evidenced by:

The facility policy titled Dementia Care, dated 4/23/24, states, in part: Policy: It is the policy of this facility to provide the appropriate treatment and services for residents who display signs of, or are diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being . Policy Explanation and Compliance Guidelines: 1. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible . 2. The care plan goals will be achievable, and the facility will provide resources necessary for the resident to be successful in meeting their goals. 3. The care plan interventions will relate to each resident's individual symptomology. 4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity . 7. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. 8. Appropriate referrals will be made if current interventions are ineffective . (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker) .

Resident R50 was admitted to the facility on [DATE REDACTED] with a diagnosis of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.

Resident R50's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/28/24, indicates Resident R50 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating Resident R50 is cognitively intact.

Of note, Resident R50's comprehensive care plan does not include her Dementia diagnosis or include goals or interventions for her care.

Resident R50's Behavior Monitoring Report for January 2025, states in part: Monitor - Behavioral Symptoms. Symptoms are to be monitored every shift, three times per day. On 1/4/25 at 12:11 PM, Resident R50's Behavior Documentation states 3= Yelling and Screaming and 8 = Abusive Language. A Y is indicated that Resident R50 has exhibited this behavior before. Ten times the behavior charting is left blank. All other days and shifts are marked as 12 = None of the behaviors occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0744 Resident R50's Behavior Monitoring Report for February 2025, states in part: Monitor - Behavioral Symptoms. Symptoms are to be monitored every shift, three times per day. On 2/14/25 at 12:32 PM, Resident R50's Behavior Level of Harm - Minimal harm or Documentation states 8 = Abusive Language. A Y is indicated that Resident R50 has exhibited this behavior before. potential for actual harm Eleven times the behavior charting is left blank. All other days and shifts are marked as 12 = None of the behaviors occurred. Residents Affected - Few

The State Operations Manual, Appendix PP, states in part: Behavioral or psychological expressions are occasionally related to the brain disease in dementia; however, they may also be caused or exacerbated by environmental triggers. Such expressions or indications of distress often represent a person's attempt to communicate an unmet need, discomfort, or thoughts that they can no longer articulate.

On 2/17/25 at 10:02 AM, Surveyor introduced self to Resident R50. Resident R50 was seated at a table in the common room (called the bird room due to the aviary being in that room). Resident R50 had papers spread on the table in front of her and was using an electronic tablet. Resident R50 did not return Surveyor's greeting or answer any questions.

On 2/17/25 at 2:27 PM, Surveyor interviewed CNA W (Certified Nursing Assistant) about Resident R50's behaviors. CNA W indicated that Resident R50 sits in the bird room all day and calls it her office, hoards items such as toilet paper rolls, refuses all showers and cares, and wears the same clothes all the time. CNA W stated that Resident R50 swears at staff every day. Surveyor asked CNA W what interventions were in place for Resident R50's behaviors. CNA W stated that she just doesn't engage Resident R50 when she gets like that. Surveyor asked CNA W if any of Resident R50's behaviors were on her CNA Kardex. CNA W indicated there was nothing on the Kardex about Resident R50's behaviors. Surveyor asked CNA W how Resident R50's behaviors were being monitored. CNA W indicated they are charted in PCC (Point Click Care) online charting system. Surveyor asked CNA W what it meant if there were blanks in the charting. CNA W indicated blanks meant that someone forgot to do the task or forgot to chart on it.

On 2/18/25 at 9:34 AM, Surveyor interviewed RN P (Registered Nurse) about Resident R50's behaviors. RN P indicated that Resident R50 refuses to do anything including take medications and allow vital sign monitoring. RN P said that Resident R50 often just tells her to go away. RN P indicated that Resident R50 watches news all day in the bird room, and if any other resident comes into the bird room, Resident R50 will yell at them to get out, or she will turn the volume up extremely loud to try to force the other resident to leave.

On 2/18/25 at 10:05 AM, Surveyor interviewed LPN X (Licensed Practical Nurse) about Resident R50's behaviors. LPN X stated that Resident R50 is very uncooperative, and they are unable to give her the care that she needs. LPN X indicated she has seen Resident R50 completely take over the bird room, and she yells at other residents when she comes in there. LPN X stated that Resident R50 will become really aggressive if anyone tries to open the window shades when she wants them closed. LPN X stated that some of the other residents used to go into the bird room to play cards, watch TV, or attend bible study, but now they don't feel comfortable going in there anymore. Surveyor asked LPN X what interventions were in place for Resident R50's behaviors. LPN X stated that

they just give Resident R50 her space.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0744 On 2/18/25 at 3:41 PM, Surveyor interviewed CNA/MT Y (Certified Nursing Assistant/Medication Technician) about Resident R50's behaviors. MT Y indicated that Resident R50 completely believes that the bird room is her office. MT Y Level of Harm - Minimal harm or stated Resident R50 will yell at anyone who attempts to change the channel, and that people used to hang out in there potential for actual harm and they don't anymore because of Resident R50's behavior. MT Y indicated that Resident R50 wants her to just leave her medications next to her and not take them right away. MT Y stated that if she does not do that, Resident R50 will Residents Affected - Few shake her fist at her and yell at her to go away. Surveyor asked MT Y what interventions were in place for Resident R50's behaviors. MT Y stated she just gives her space and walks away, because if she doesn't, Resident R50 will just continue yelling and yelling until you leave her alone.

On 2/19/25 at 10:26 AM, Surveyor interviewed RN I (Registered Nurse) about Resident R50's behaviors. RN I indicated there have been many days that Resident R50 has screamed at her over the TV channel or the lights being

on when she wants them off. RN I stated that Resident R50 will target certain residents and yell at them if she thinks

they are taking her things out of the bird room. RN I stated that Resident R50 has also chased family members out of

the room by screaming at them, and that Resident R50 screamed and cussed at a volunteer who came to do bible study in the bird room. RN I indicated bible study and other activities had to be moved to another area of the community, because other residents are intimidated by Resident R50. RN I stated that Resident R50 also refuses all nursing care. Surveyor asked RN I what interventions are in place for Resident R50's behaviors. RN I stated that they just give her space because she is not agreeable to anything. RN I stated that the more they try to talk to Resident R50, the more she ignores them like they don't exist, or she explodes to screaming and yelling. RN I indicated that

this behavior has been going on for months.

On 2/19/25 at 1:06 PM, Surveyor interviewed DON B (Director of Nursing) about Resident R50's behaviors. Surveyor asked if a resident has behaviors, should they be on their care plan. DON B stated yes, behaviors should be listed on the care plan. Surveyor asked DON B what kind of behaviors Resident R50 was having. DON B indicated that Resident R50 acts like the bird room is her office. DON B stated that Resident R50 knows it is not her office but she feels that she is entitle to use it as her office. DON B stated that Resident R50 has never been physically aggressive but can become very argumentative with staff and other residents. Surveyor asked DON B if a resident has a diagnosis of dementia, should that be on their care plan, along with triggers and interventions for behaviors. DON B stated yes, dementia should be on Resident R50's care plan. Surveyor asked DON B if Resident R50's dementia diagnosis, her behaviors, and any interventions were not on Resident R50's care plan, how would a new employee know how to care for Resident R50. DON B indicated that it would be hard for a new employee to know how to de-escalate Resident R50's behaviors. DON B stated it was his expectation that Resident R50's dementia including her behaviors and interventions should be in place on Resident R50's care plan and CNA Kardex.

The facility failed to assess, develop, and implement an individualized care plan to ensure that Resident R50's dementia care needs were met.

Cross Reference:

F-F744

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49436

Residents Affected - Few Based on record review and staff interviews, the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 1 of 20 total sampled residents (Resident R23).

Resident R23's medical record indicates he has schizoaffective disorder and behaviors. Resident R23's comprehensive care plan does not include a care plan with goals or interventions that included monitoring and supervision, related to inappropriate behaviors.

This is evidenced by:

The facility's policy titled Comprehensive Care Plan, dated 9/23/22, states in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive care plan.

The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. The comprehensive care plan will be reviewed and revised as appropriate by the interdisciplinary team after each comprehensive and quarter MDS assessment, and as needed with changes

in condition. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs .Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Resident R23 admitted to the facility on [DATE REDACTED] with diagnoses that include schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), severe obsessive-compulsive disorder (excessive thoughts that lead to repetitive behaviors) and anxiety.

Resident R23's Brief Interview for Mental Status on 1/5/25 has a score of 15, indicating Resident R23 is cognitively intact.

Resident R23's annual MDS (Minimum Data Set) comprehensive assessment dated [DATE REDACTED] states in part: Resident R23 has verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. Care areas triggered for care planning include psychosocial well-being and behavioral symptoms.

Resident R23's comprehensive care plan, printed 2/19/25, does not include psychosocial well-being or behavioral symptoms.

Resident R23's physician orders for February 2025 do not include behavior monitoring orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0656 Resident R23's behavioral health assessment, dated 1/21/25, states in part: He does have some paranoid delusions at baseline. Level of Harm - Minimal harm or potential for actual harm Resident R23's CNA (Certified Nursing Assistant) documentation for January 2025 indicates 23 shifts for the month where Resident R23 had behavioral symptoms of yelling/screaming, repeated movements, abusive language, and/or Residents Affected - Few rejection of cares.

Resident R23's CNA documentation for February 2025 indicates 10 shifts where Resident R23 had behavioral symptoms of yelling/screaming, repeated movements, abusive language, and/or rejection of cares.

On 2/18/25 at 9:25 AM, Surveyor interviewed MT M (Med Tech, a CNA that can administer medications) regarding Resident R23's behaviors. MT M indicates Resident R23 will get upset, swear, and lash out verbally. MT M indicated when he becomes behavioral, MT M will try to calm him down by talking to him. MT M did not indicate other interventions that may help when Resident R23 becomes behavioral.

On 2/18/25 at 9:27 AM, Surveyor interviewed CNA U regarding Resident R23's behaviors. CNA U indicated Resident R23 will get upset and say nasty things, but then he will apologize later. CNA U indicated when Resident R23 become behavioral, CNA U will try to redirect him or get another staff member to come help. CNA U did not indicate other interventions that may help when Resident R23 becomes behavioral.

On 2/18/25 at 9:58 AM, Surveyor interviewed RN V (Registered Nurse) regarding Resident R23's behaviors. RN V indicated Resident R23 will become manic, will start calling people on the phone and demand phone numbers, will yell at people, and becomes fixated on a topic. RN V indicated calling Resident R23's sister to speak with him will help. RN V indicated if a resident had behaviors, the care plan would show what the behaviors are and what interventions to use.

On 2/19/25 at 12:58 PM, Surveyor interviewed DON B (Director of Nursing) regarding Resident R23's behaviors. DON B indicated if a resident has behaviors, there would be an order in the physician orders for behavior monitoring every shift. DON B indicated if a resident has behaviors, the residents care plan should be updated to include that information. Surveyor informed DON B that Resident R23 does not have a care plan that includes triggers, goals, or interventions for his behaviors. DON B indicated it would be difficult for staff to know what Resident R23's behaviors are and what de-escalation interventions are effective for Resident R23 without a care plan. DON B indicated Resident R23 should have a care plan for his behaviors that includes interventions but does not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0679 Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44552 potential for actual harm Based on observation, interview, and record review, the facility failed to provide an ongoing program to Residents Affected - Some support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident for 2 (Resident R38 and Resident R58) of 20 total sampled Residents and 2 (Resident R33 and Resident R25) of 12 supplemental residents who reside on D Hallway.

Surveyor observed Resident R38, Resident R58, Resident R33 and Resident R25 from 2/16/25-2/18/25. The facility did not provide residents with meaningful activities.

Evidenced by:

The facility policy, Activities, dated 7/11/22, states, in part; .2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being, belonging, and usefulness. b. Promote or enhance physical activity. c. Promote or enhance cognition. d. Promote or enhance emotional health. e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence. f. Reflect resident's interests and age. g. Reflect cultural and religious interests of the residents. h. Reflect choices of the residents .9. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs .

Example 1

Resident R38 was admitted to the facility on [DATE REDACTED] with a diagnoses including Alzheimer's disease, Dementia with psychotic disturbance, restless leg syndrome, essential tremor, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down).

Resident R38's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/21/25, indicates Resident R38 has a BIMS (Brief Interview for Mental Status) score of 08 indicating Resident R38 is moderately cognitively impaired. Resident R38 has an activated power of attorney.

Resident R38's Comprehensive Care Plan, states, in part; .While in the facility, Resident R38 states that it's important that she engage in activities that are meaningful to her preferences/interest 10/22/24 .I am catholic faith and would like to participate in religious services/practices such as attending in-house services and self-directing my own prayer. I enjoy socializing with others, spending time with family/friends, keeping up with the morning news, country music, baking/cooking, being around children, balloon ball, and watching TV/movies. I also like to sit/relax and socialize outdoors; I prefer warm weather. I used to enjoy making cards, coloring, and parties/socials. It is important for me to engage in my favorite activities .I would benefit from accommodations from physical limitations by having assistance to/from programs. I would benefit from accommodations from visual limitations by having large print materials. I would like pet visits, if available, and I enjoy dogs .I would like to vote, if able .

Surveyor reviewed Resident R38's activity participation documentation from December 2024 and January 2025. There are 21 days with no activity participation documentation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0679 Surveyor observed Resident R38 on 2/16/25. Resident R38 was not offered and did not participate in any activities. Resident R38's activity documentation for 2/16/25 was blank. Level of Harm - Minimal harm or potential for actual harm On 2/16/25 at 2:18 PM, Resident R38 indicated the facility is short staffed and this concerns Resident R38. Resident R38 indicated she would like to be offered different things to do. Residents Affected - Some Surveyor observed Resident R38 on 2/17/25. Surveyor did not observe Resident R38 participating in any activities. Surveyor reviewed Resident R38's activity documentation for 2/17/25, Resident R38 participated in watching a movie for the entire day.

Surveyor observed Resident R38 on 2/18/25. At 10:35 AM, Resident R38 went and got her nails done and returned to D hallway shortly after. Resident R38 did not participate in any other activities.

Example 2

Resident R33 was admitted to the facility on [DATE REDACTED] with a diagnoses including Alzheimer's disease, adjustment disorder with depressed mood, unspecified hearing loss, and dementia with anxiety.

Resident R33 most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/4/24, indicates Resident R33 has a BIMS (Brief Interview for Mental Status) score of 00 indicating Resident R33 is severely cognitively impaired. Resident R33 has an activated power of attorney.

Resident R33's Comprehensive Care Plan, states, in part; .it is important that she engage in activities that are meaningful to her preferences/interest .I enjoy looking through magazines/the newspaper, baking/cooking, observing programs, attending social/special events, watching TV/movies, socializing with others, doing word search puzzles, and playing cards-dirty clubs. I use to enjoy the news, working in my flower garden, walking to my son's house, and traveling. I also like to sit/relax in nature and outdoors when the weather is nice. I prefer hot/warm and sunny weather. It is important for me to engage in my favorite activities 9/7/21 .

Surveyor reviewed Resident R33's activity documentation from December 2024 and January 2025. There are 22 days with no activity participation documented.

Surveyor observed Resident R33 on 2/16/25. Resident R33 was not offered and did not participate in any activities. Resident R33's activity documentation for 2/16/25 was blank.

Surveyor observed Resident R33 on 2/17/25. Surveyor did not observe Resident R33 participating in any activities. Surveyor reviewed Resident R38's activity documentation for 2/17/25, Resident R33 participated in watching a movie for the entire day.

Surveyor observed Resident R33 on 2/18/25. Resident R33 did not participate in any activities in the morning. At 1:55 PM, activity staff assisted Resident R33 in attending the baking activity in the activity room until 3 PM. Resident R33 did not participate in any other activities.

Example 3

Resident R25 was admitted to the facility on [DATE REDACTED] with a diagnoses including dementia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0679 Resident R25's most recent MDS (Minimum Data Set) with ARD (Assessment Reference date) of 12/12/24, indicates Resident R25 has a BIMS (Brief Interview for Mental Status) score of 03 indicating Resident R25 is severely cognitively Level of Harm - Minimal harm or impaired. Resident R25 has an activated power of attorney. potential for actual harm Resident R25's Comprehensive Care Plan, states, in part; .it is important that she engages in activities that are Residents Affected - Some meaningful to her .I prefer to keep to myself. I do enjoy reading the newspaper and magazines, resting/laying down, listening to all kinds of music, socializing with others, doing word search puzzles and watching TV/movies. I also like to sit/relax, socials, and nature watch outdoors when the weather is nice; I prefer warm/cool weather. I use to enjoy bingo, sewing/knitting, and having a vegetable garden. It is important for me to engage in my favorite activities .12/13/23 .I would benefit from accommodations from cognitive limitations by having reminders for programs, verbal/physical prompts, single step direction, and assistance to/from programs .I would benefit from accommodations from hearing limitations by having placement near

the speaker/leader of the program .I would benefit from accommodations from physical limitations by having assistance to/from program .

Surveyor reviewed Resident R25's activity participation documentation for December 2024 and January 2025. There are 22 days with no activity participation documented.

Surveyor observed Resident R25 on 2/16/25. Resident R25 was not offered and did not participate in any activities. Resident R25's activity documentation for 2/16/25 was blank.

Surveyor observed Resident R25 on 2/17/25 and 2/18/25. Surveyor did not observe Resident R25 participate in any activities. Surveyor reviewed Resident R25's activity participation documentation. Resident R25 listened to the radio.

Example 4

Resident R58 was admitted to the facility on [DATE REDACTED] with a diagnoses including cognitive communication deficit, weakness, anxiety disorder, major depressive disorder, and mild cognitive impairment.

Resident R58's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 1/6/25, indicates Resident R58 has a BIMS (Brief Interview for Mental Status) score of 08 indicating Resident R58 is moderately cognitively impaired. Resident R58 has an activated power of attorney.

Resident R58's Comprehensive Care Plan, states, in part; .it's important that she engage in activities that are meaningful to her preferences/interest .I am of the catholic faith and would like to participate in religious services such as self-directing my own prayer and possibly attending in-house services. I enjoy socializing with others, coloring, keeping up with the local news, listening to classic country music, reading all kinds of materials, car rides and watching TV. I use to enjoy gardening/plants. I also like to sit/relax outdoors, and I prefer warm weather. It is important for me to engage in my favorite activities 1/6/25 .

Surveyor observed Resident R58 on 2/16/25. Resident R58 was not offered and did not participate in any activities. Resident R58's activity documentation for 2/16/25 was blank.

On 2/16/25 at 2:57 PM, Resident R58 asked what there was to do. Staff indicated Resident R58 could go to the bathroom. Resident R58 indicated that's something to do and she could go to the bathroom. Surveyor asked Resident R58 if she would like some activities and things to do. Resident R58 indicated she would like that.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0679 On 2/17/25 at 2:18 PM, CNA BB (Certified Nursing Assistant) indicated there is often one CNA down D hallway and with the population they serve down D hallway it gets very chaotic. There are not activity aides Level of Harm - Minimal harm or or any activities during the weekends. CNA BB indicated the activities are not geared for residents with potential for actual harm dementia. CNA BB indicated she has voiced these concerns, and nothing had changed. CNA BB indicated more activities and activities that are tailored for residents with dementia would benefit everyone down D Residents Affected - Some hallway.

On 2/18/25 at 9:45 AM, CNA KK indicated there are not a lot of activities offered for residents on D hallway. CNA KK indicated the activities are not for residents with dementia.

On 2/18/25 at 10:43 AM, Surveyor asked LPN X (Licensed Practical Nurse) about activities for the residents

on D hallway. Surveyor asked about activities specifically for residents with dementia. LPN X indicated she was unsure what was offered for the residents on D hallway. LPN X indicated, They all look so bored.

On 2/19/25 at 9:13 AM, LES NN (Life Enrichment Specialist) indicated she always encourages her staff to include the residents on D hallway for all activities. LES NN indicated she will stress more to her staff about encouraging all residents to attend activities. LES NN indicated she will follow up with her staff regarding weekend activities as well. LES NN indicated she has some good staff on the team now and there has been improvements. LES NN indicated she tries to keep the bigger activities scheduled on the same days and there are items down D hallway so the residents can use items such as coloring pages, books, and puzzles. Surveyor asked LES NN how do you ensure residents that are not independent with activities still have meaningful activities and are included? LES NN indicated she always asks residents at resident council about activities and what they would like to see on the calendar. LES NN indicated they will pair up residents and try to bring as many residents as possible down to activities. LES NN indicated the resident might prefer to watch and observe an activity and it is important for them to still be invited and included in that activity. LES NN indicated staff will reapproach the resident as well if they at first decline joining the activity. LES NN indicated they do the best they can for including the residents that have dementia and may need more support. LES NN indicated Resident R38, Resident R58, and Resident R33 can be independent with activities. LES NN indicated Resident R25 is more difficult in finding activities that she may enjoy participating in. Surveyor shared with LES NN

observations regarding residents down D hallway and activities. LES NN indicated CNA's can assist with activities as well and assist in setting up residents with activities. Surveyor indicated if there is one CNA down D hallway there might not be a lot of time to do activities. LES NN stated yes that is true. LES NN indicated she will provide education to her weekend staff and that Wednesday and Thursday are better down D hallway.

On 2/19/25 at 12:30 PM CNA M indicated Resident R38, Resident R58, Resident R33, and Resident R25 are not independent with their activities. CNA M indicated the residents need assistance and support from staff for activities.

On 2/19/25 at 12:36 PM, CNA Z indicated Resident R38, Resident R58, Resident R33, and Resident R25 need assistance with activities. CNA Z indicated they are not independent or able to structure their own activities.

On 2/19/25 at 1:20 PM, NHA A (Nursing Home Administrator) indicated understanding regarding the concern with the lack of activities for the residents on D hallway.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0679 The facility failed to provide an on going program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident who resides at the facility. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

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

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42038 jeopardy to resident health or safety Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident Residents Affected - Few with PIs receives necessary treatment and services to promote healing and prevent new injuries from developing for 2 of 5 residents (Resident R35 and Resident R44) reviewed for pressure injuries.

Resident R35 was at risk for PI development. Resident R35 developed two stage 3 facility acquired PIs that deteriorated.

Observations were made of multiple layers between Resident R35 and the air mattress. The facility failed to provide education and/or risks vs benefits when Resident R35 declined repositioning. Staff did not ensure consistent documentation of repositioning or incontinence care, which were noted contributors to Resident R35's PIs. Staff did not protect Resident R35's periwound when applying the prescribed treatment.

The facility's failures to implement preventive interventions for residents at risk for PIs, failure to provide education and/or risks vs. benefits when a resident declined repositioning, and failure to correctly apply a prescribed treatment created a finding of immediate jeopardy that began on 1/15/25. Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on 2/28/25 at 10:05 AM. The immediate jeopardy was removed on 2/28/25; however, the deficient practice continues at a scope/severity of G (actual harm/isolated) as the facility continues to implement their action plan as evidenced by:

Resident R44 was admitted with a pressure injury. The facility failed to complete weekly pressure injury assessments per standards of practice. Observations were made of multiple layers between Resident R44 and the air mattress. Resident R44's PI deteriorated as evidenced by undermining and tunneling.

Evidenced by:

The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer, and identify related causes and complications.

The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories:

Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue Level of Harm - Immediate loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by jeopardy to resident health or anatomical location. safety Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in Residents Affected - Few which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose

the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.

Wound Source article titled Pressure Injury and Microclimate: How Linen Layers May Contribute dated 2/14/24 states in part, . Pressure Injury Risk: How Linen Layers May Contribute: Linen layers have the potential to impact skin microclimate in the following ways:

Reduce airflow

Affect pressure redistribution

Increase friction coefficient

Dry or macerate skin

Increase skin temperature

Clinicians should select the correct type and amount of layers between the patient and support surface. Evidence suggests this selection is a high-value, low-cost, intervention. Regarding linen type, the NPIAP 2019 guidelines specifically recommend the use of silk or silk-like sheets versus cotton and cotton blend sheets .

Regarding linen number, experts have found that incontinence pads, transfer sheets, or a combination of linens can significantly increase the mean peak sacral pressure when compared to a single flat sheet. Even

on both a low-air-loss surface and foam surface, regardless of head-of-bed angle, pressure may be increased. This occurrence was confirmed by an in vitro study by [NAME] et al which examined the effect on interface pressures with the use of wet and dry incontinence pads against the gluteal and sacral areas of mannequins with soft, tissue-like qualities. In a 2018 retrospective review using International Pressure Ulcer Prevalence data from 216,626 participants, additional linen layers were found as a risk factor for both superficial and severe pressure injuries . Pressure Injury and Microclimate: How Linen Layers May Contribute | WoundSource

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 The facility's policy titled Pressure Injuries and Non pressure Injuries last reviewed on 7/20/2022, states in part, .Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and Level of Harm - Immediate granulation tissue and epibole (rolled wound edges) are often present .Additional Skin Impairment jeopardy to resident health or Definitions: Moisture Associated Skin Damage: inflammation of the skin and erosion from prolonged safety exposure to moisture and its [sic] contents. Common sources of moisture include urine and stool, perspiration, wound exudate, and effluent from an ostomy .2. Weekly: a. Complete a head-to-toe skin check Residents Affected - Few and document findings on the Skin Review .If new areas are present: i. notify MD (Medical Doctor) ii. Notify resident/ responsible party iii. Initiate treatment per order .b. Assess current wounds at least every 7 days, or more frequently as needed (e.g., decline in wound, presence of infection, wound healed) .

Example 1:

Resident R35 was admitted to the facility on [DATE REDACTED], and was readmitted to the facility after a hospitalization on [DATE REDACTED] with diagnoses that included osteomyelitis of vertebra (infection in the spine), type 2 diabetes mellitus, morbid obesity, and radiculopathy of lumbar region (a condition where nerve roots on the lower back are compressed or irritated, causing pain and other symptoms that radiate down the leg-numbness, tingling, burning, weakness or muscle spasms, difficulty walking or standing, loss of reflexes in the leg).

Resident R35's most recent MDS (Minimum Data Set) dated 1/6/25 states that Resident R35 has a BIMS (Brief Interview for Mental Status) of 13 out of 15, indicating that Resident R35 is cognitively intact. The MDS also indicates that Resident R35 is dependent on staff for toileting, bathing, transfers, and bed mobility. Resident R35 is always incontinent of bowel and bladder and has paralysis of her lower extremities.

Resident R35's care plan dated 11/21/24 and revised on 1/30/25 states in part:

Interventions: *Administer treatments as ordered and monitor for effectiveness (initiated 11/21/24). *Monitor dressing to ensure it is intact and adhering. Report lose [sic] dressing to treatment nurse (revised 12/10/24). *Monitor nutritional status. Serve diet as ordered, monitor intake and record (initiated 12/10/24). *Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size ., stage (initiated 11/21/24). *Resident is to be turned and repositioned in even hours using a wedge and may be on back for meals only, more often as needed or requested (initiated 1/30/25). *The resident requires the bed to be as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people (revised 12/10/24). The resident requires air flotation mattress on bed (initiated 12/10/24). Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort (initiated 12/10/24). Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate (initiated 12/10/24) .

It is important to note that Resident R35's care plan was not updated to reflect current wounds and locations. Resident R35's repositioning intervention was added 22 days after the development of the PI.

Resident R35's Braden Scale (for predicting pressure sore risk) scores are as follows:

11/27/24: 16-at risk

12/6/24: 16-at risk

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 12/13/24: 15-at risk

Level of Harm - Immediate 1/10/25: 16-at risk jeopardy to resident health or safety 1/17/25: 14-moderate risk

Residents Affected - Few 1/24/25: 14-moderate risk

Resident R35's weekly skin checks since readmission, indicate the following:

1/9/25: dry skin

1/16/25: pressure injury to coccyx

1/23/25: coccyx stage 2, left gluteal fold (boundary between the buttocks and posterior (back) of thigh)

1/30/25: coccyx stage 2, left gluteal fold

2/6/25: coccyx wound

2/13/25: PI - buttock

Resident R35's Non-Pressure Weekly Tracker documentation is as follows:

1/8/25: .2. Wound acquired: b. In house. 2a. Date acquired: 1/8/25. 3. Type: h) Open area. 4. Location: Lower gluteal cleft buttock .5a. Length 4.8 cm (centimeters) 5b. Width 2.7cm. 5c. Depth 0.1cm .7. Drainage e. purulent. 8. Amount of drainage b. light .23. Comments: MASD (Moisture Associated Skin Damage) .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Zinc ointment apply Q (every) shift 3xday (3 times a day) for 30 days Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; off- load wound; reposition per facility protocol; turn side to side

in bed every 1-2 hours if able .

1/15/25: . 4. Location: Coccyx. Description: Wound area previously documented as MASD has now progressed to stage 3 pressure injury .5a. Length 3.4 cm 5b. Width 1.9cm. 5c. Depth 0.1cm .Tissue Type . 6c. Granulation 30% 6d. Slough 70% .7. Drainage b. Serous. 8. Amount of drainage c. moderate .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Leptospermum honey to wound bed followed by duoderm (adhesive dressing) 3x/week (3 times per week) Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; off- load wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well .

It is important to note despite the MASD deteriorating to a stage 3 pressure injury (PI) the facility continued to document this PI on the facility's non-pressure wound tracker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 1/22/25: .5a. Length 14.7 cm 5b. Width 2cm. 5c. Depth 0.4cm .Tissue Type .6c. Granulation 30% 6d. Slough 70% .7. Drainage b. Serous. 8. Amount of drainage d. heavy .23. Comments: MASD- Wound area previously Level of Harm - Immediate documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to jeopardy to resident health or be closed and completed, new tracker will be opened. Exacerbated due to increased drainage and safety noncompliant with offloading .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Santyl apply once daily followed by calcium alginate. Skin prep peri wound. Cover with foam with border Residents Affected - Few daily. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well .

Of note: on 1/22/25 the PI deteriorated by increasing in size, heavy drainage. Despite staff noting Resident R35 was noncompliant with offloading, there is no evidence of education or risks vs benefits being provided.

Resident R35's MAR (Medication Administration Record) has the following order:

* Ensure resident is being repositioned every 2 hours. Every shift. Start date: 1/30/25. The following dates and shifts are marked no: 2/1/25 PM (evening) shift, 2/5/25 PM shift, and 2/14/25 PM and NOC (night) shifts.

Of note: Resident R35's order to be repositioned was not added to the MAR until 1/30/25.

1/29/25: . stage 3 pressure injury .5a. Length 18.2 cm 5b. Width 3.2cm. 5c. Depth 0.2cm .Tissue Type .6c. Granulation 70% 6d. Slough 10% 6e. Necrotic 20% .7. Drainage b. Serous. 8. Amount of drainage c. moderate .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened. Exacerbated due to increased drainage and incontinence .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Sodium hypochlorite (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary dressing(s) ABD pad apply once daily for 30 days. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well .

2/5/25: . stage 3 pressure injury .5a. Length 14.1 cm 5b. Width 10.1cm. 5c. Depth 0.3cm .Tissue Type .6a. Skin 10% 6d. Slough 85% 6e. Necrotic 5% .7. Drainage b. Serous. 8. Amount of drainage c. moderate .23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened. Exacerbated due to increased drainage and incontinence .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Sodium hypochlorite (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary dressing(s) ABD pad apply once daily for 30 days. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 Of note: Resident R35's PI now has 85% slough in the wound bed when on 1/29/25 Resident R35's wound bed had 70% granulation and only 20% necrotic tissue, which would indicate a deterioration in the wound. Level of Harm - Immediate jeopardy to resident health or 2/12/25: . stage 3 pressure injury .5a. Length 12.5 cm 5b. Width 3.6cm. 5c. Depth 0.4cm .Tissue Type .6a. safety Skin 10% 6c. Granulation 50% 6e. Necrotic 50% .7. Drainage b. Serous. 8. Amount of drainage c. moderate . 23. Comments: MASD- Wound area previously documented as MASD has now progressed to stage 3 Residents Affected - Few pressure injury of coccyx as of 1/15/25. This tracker to be closed and completed, new tracker will be opened. Improved evidenced by decreased surface area .6. Additional interventions/plans: Dressing treatment Plan Primary Dressing(s) Sodium hypochlorite (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary dressing(s) ABD pad apply once daily for 30 days. Plan of care reviewed and addressed Recommendations cleanse with wound cleanser at time of dressing change; offload wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able. [Wound Care Doctor] here to eval and treat resident. Surgical excisional debridement procedure completed at bedside. Resident tolerated well .

(Of note: the PI assessment indicates 110% as evidenced by Skin 10% 6c. Granulation 50% 6e. Necrotic 50%. Assessments should never account for more than 100%. Facility staff did not clarify the characteristics of the wound bed or that the percentage was over 100%)

The following documentation is regarding Resident R35's second pressure injury that developed that was found as an unstageable.

1/15/25: . 2. Pressure injury acquired b. In house. 2a. Date acquired 1/15/25. 3. Location: Right thigh (rear) type: pressure. Length 0.5cm Width 1.1cm Depth 0.1cm Stage 3 .5. Tissue Type .5d. Slough 100% .6. Drainage: b. Serous. 7. Amount of drainage: b. light .6. Additional interventions/plans: [Wound Care MD] here to eval and treat. Treatment plan as follows: Cleanse with wound cleanser at time of dressing change, apply silver sulfadizine 3x/week and PRN for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well .

(Of note: Resident R35's left thigh wound was found as a stage 3, on 1/15/25 which is the same day that Resident R35's MASD deteriorated to a stage 3 pressure injury. The wound has 100% slough which would indicate the wound is an unstageable Pressure injury.)

1/22/25: . 3. Location: Left thigh (front) type: pressure. Length 6.5cm Width 6.3cm Depth 0.1cm Stage 3 .5. Tissue Type .5a. Skin 60% 5c. Granulation 40% 5d. Slough 20% .6. Drainage: b. Serous. 7. Amount of drainage: d. heavy .20. Comments: .Previously documented as right posterior thigh in error. Area is LEFT posterior thigh/buttock .6. Additional interventions/plans: [Wound Care MD] here to eval and treat. Treatment plan as follows: Cleanse with wound cleanser at time of dressing change, apply silver sulfadizine 3x/week and PRN for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well .

(Of note: Of note: the PI assessment indicates 120% as evidenced by Skin 60% 5c. Granulation 40% 5d. Slough 20%. Facility staff did not clarify the characteristics of the wound bed or that the percentage was over 100%.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 1/29/25: . 3. Location: Left thigh (rear) type: pressure. Length 2.5cm Width 2.2cm Depth 0.1cm Stage 3 .5. Tissue Type .5c. Granulation 30% .5e. Necrotic 70% .6. Drainage: b. Serous. 7. Amount of drainage: c. Level of Harm - Immediate moderate .20. Comments: .Previously documented as right posterior thigh in error. Area is LEFT posterior jeopardy to resident health or thigh/buttock. Improved as evidenced by decrease in surface area .6. Additional interventions/plans: [Wound safety Care MD] here to eval and treat resident. Treatment plan as follows: Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily and as needed for 30 days: 0.125% Residents Affected - Few dakins Secondary Dressing(s) ABD pad apply once daily for 30 days. Peri wound treatment Zinc ointment apply once daily and as needed for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well .

2/5/25: . 3. Location: Left thigh (rear) type: pressure. Length 0.4cm Width 1.7cm Depth 0.1cm Stage 3 .5. Tissue Type .5d. Slough 100% .6. Drainage: b. Serous. 7. Amount of drainage: b. Light .20. Comments: . Previously documented as right posterior thigh in error. Area is LEFT posterior thigh/ buttock. Improved as evidenced by decrease in surface area .6. Additional interventions/plans: [Wound Care MD] here to eval and treat resident. Treatment plan as follows: Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary Dressing(s) ABD pad apply once daily for 30 days. Peri wound treatment Zinc ointment apply once daily and as needed for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well .

2/12/25: 3. Location: Left thigh (rear) type: pressure. Length 1.4cm Width 1.6cm Depth 0.1cm Stage 3 .5. Tissue Type .5c. Granulation 100% .6. Drainage: b. Serous. 7. Amount of drainage: b. Light .20. Comments: . Previously documented as right posterior thigh in error. Area is LEFT posterior thigh/buttock. Improved as evidenced by decrease in surface area .6. Additional interventions/plans: [Wound Care MD] here to eval and treat resident. Treatment plan as follows: Dressing Treatment Plan Primary Dressing(s) Sodium hypochlorite solution (dakins) apply once daily and as needed for 30 days: 0.125% dakins Secondary Dressing(s) ABD pad apply once daily for 30 days. Peri wound treatment Zinc ointment apply once daily and as needed for 30 days. Surgical excisional debridement completed at bedside via [MD name]. Removal of necrotic tissue and established margins of viable tissue. Resident tolerated procedure well .

Resident R35's CNA (Certified Nursing Assistant) documentation from 1/1/25-2/17/25 is as follows:

Task: Did you turn and reposition? Response: Yes-58 answers out of 144 opportunities.

It is important to note that the facility failed to document on 86 repositioning opportunities.

B&B: Bowel and Bladder Elimination: January and February-bowel movements tracked and documented daily on most shifts. Urination is not tracked at all.

On 2/18/25 at 9:30 AM, Surveyor observed wound care with DON B (Director of Nursing) and LPN EE (Licensed Practical Nurse). Surveyor observed Resident R35 lying in bed with a low air loss mattress. Resident R35 had several layers underneath her; the bed had a fitted sheet, a lift sheet, a cloth chux pad, an incontinence brief, and a purple incontinence liner that was saturated with urine. Wound care was completed by LPN EE, and a new incontinence brief and purple incontinence liner was reapplied.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 On 2/19/25 at 9:48 AM, Surveyor interviewed LPN EE. Surveyor asked LPN EE how she can ensure that the Dakin solution isn't touching the healthy skin after changing Resident R35's dressing, LPN EE stated that she tries to Level of Harm - Immediate form it to the wound. Surveyor asked how they know that it stays in place when being changed or jeopardy to resident health or repositioned, LPN EE stated that staff have to make sure it is in place, but she is not sure. safety

It is important to note, that during wound care, the Dakin-soaked gauze was lying flat on the wound bed, not Residents Affected - Few tucked into the wound, and was coming in contact with healthy skin.

According to the National Library of Medicine< https://www.ncbi.nlm.nih.gov/books/NBK507916/> Due to its properties as an acid-based compound, Dakin solution can be corrosive to healthy tissue, especially at higher concentrations. An oil-based ointment such as petroleum jelly can be applied to surrounding healthy tissue to reduce skin irritation and prevent the debridement of viable tissue. Dakin solution also loses its antiseptic properties rapidly after application due to the instability of the compound. Therefore, gauze sponges soaked with Dakin used to pack necrotic wounds must be frequently changed. It is usually applied twice daily to lightly to moderately exudative wounds and twice daily for highly exudative or contaminated wounds.

On 2/19/25 at 8:58 AM, Surveyor interviewed CNA E. Surveyor asked CNA E how often Resident R35 is checked and changed, CNA E stated every 2 hours and is repositioned every 2 hours from side to side. Surveyor asked CNA E if they document repositioning and toileting, CNA E stated that they don't. Surveyor asked how many layers should be under a resident on an air mattress, CNA E reported that there should be a fitted sheet, a draw sheet, and a brief. Surveyor asked if she has ever noticed Resident R35 to have a fitted sheet, draw sheet, cloth chux pad, purple liner, and an incontinence brief on, CNA E yes. Surveyor asked if she reported it to anyone, CNA E stated no and that she just removes it.

On 2/18/25 at 3:23 PM, Surveyor interviewed CNA MM. Surveyor asked how many layers are under Resident R35, CNA MM reported a sheet, a draw sheet, a cloth chux pad, and a purple incontinence liner. Surveyor asked how often is Resident R35 repositioned, CNA MM stated every 2 hours and that they document it and they used to have a paper they filled out, but now it's added to her tasks.

On 2/18/25 at 1:48 PM, Surveyor interviewed DON B. Surveyor asked DON B how many layers should be under a resident that is on an air mattress, DON B stated that it should be just the sheet. Surveyor asked DON B if he observed all of the layers under Resident R35, DON B stated yes. Surveyor asked DON B if they have identified the root cause of Resident R35's coccyx wound worsening. DON B provided documentation from the wound MD indicating it was due to Resident R35 refusing offloading and due to incontinence. DON B reported that they obtained an order for a wedge cushion on 1/24/25 and implemented that, as well as adding turn every 2 hours to Resident R35's CNA tasks. DON B also stated that he added Bowel and Bladder documentation to the CNA task list. Surveyor reviewed CNA documentation with DON B. Surveyor asked DON B how he knows that Resident R35 is being repositioned every 2 hours, if the task only asks if she was repositioned, DON B stated he wasn't sure. Surveyor also reviewed Resident R35's bowel and bladder documentation and pointed out that the CNAs were not documenting Resident R35's incontinence episodes.

Resident R35 was at risk for PI development and developed two stage 3 facility acquired PIs. The facility failed to follow standards of practice as evidenced by observations of multiple layers between Resident R35 and the air mattress, failed to provide education and/or risks vs benefits when Resident R35 declined repositioning, did not ensure consistent documentation of repositioning, and failed to ensure treatments were applied to only the pressure injury wound bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 The facility's failure to implement preventive interventions for residents at risk for PIs, failure to provide education and/or risks vs. benefits when a resident declined repositioning, failure to complete weekly Level of Harm - Immediate assessment per standard of practice, and failure to correctly apply prescribed treatments created a jeopardy to resident health or reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed safety the jeopardy on 2/28/25, when it completed the following:

Residents Affected - Few *Both residents remains at the center and care plan regarding pressure injury reviewed and updated. In house residents with pressure injuries have the potential to be affected. Skin sweep completed 2/28/2025.

On 2/28/2025 Director of nursing or designee implemented re-education with nursing staff (CNAs and licensed nurses) on Pressure Injury and Non-Pressure Injury policy and Use of Support Surface policy. This education included:

o the need to ensure care plan is followed including managing moisture and incontinence including not using multiple layers with air mattresses

o If cares/treatments are refused to notify licensed nurse/DON/designee and education provided on risks and benefits to resident or responsible party, notify MD and update care plan

o obtaining Periwound treatment in order from MDs

o Wound assessments including measurements and ensuring surface area adds up to 100% of assess

Identified education will occur prior to start of next scheduled shift.

On 2/28/2025, facility reviewed their Pressure Injury and Non-Pressure Injury and Use of Support Surface policies. No changes were required to policies. On 2/28/25, DON/designee also verified that residents with pressure injuries have accurate assessment of pressure injuries, including physician orders for treatment and dressing changes that are completed per MD order. Interdisciplinary review completed of care plans for residents with pressure injuries and a visual audit was completed by Director of Nursing or designee to ensure care planned interventions for pressure injury healing and prevention are in place.

DON/designee to complete random observation (audit) of dressing changes per MD order with periwound treatment, if warranted, and cares/treatment to ensure dressing changes completed per MD order, interventions to promote healing including no multiple layers on air mattresses, and ensure proper documentation of refusal of skin care and treatment. Audits will also include Pressure injury weekly documentation to ensure accurate and complete, and CNA task documentation on if cares accepted and documented per care plan. Audits will be completed daily x 7 days. These audits will then continue on varying shifts three times per week for 4 additional weeks then 2 times per week for 4 additional weeks. Results of audits will be presented to facility QAPI committee for review and any recommendations.

Ad hoc QAPI meeting held on 2/28/2025 to review this plan

Example 2:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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

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

F 0686 Resident R44 was admitted to the facility on [DATE REDACTED] with diagnoses to include type 2 diabetes mellitus, pressure ulcer of sacral region, stage 2, anxiety disorder, and panic disorder. Level of Harm - Immediate jeopardy to resident health or Resident R44's most recent MDS dated [DATE REDACTED] states that Resident R44 has a BIMS of 15 out of 15, indicating that Resident R44 is safety cognitively intact. The MDS also indicates that Resident R44 is dependent on staff for bed mobility, transfers, bathing, and dressing her lower body. Residents Affected - Few Resident R44's care plan initiated on 12/17/24 states: .Focus: The resident has a stage 2 pressure ulcer to coccyx or potential for pressure ulcer development r/t Hx (history) of ulcers, decreased mobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions: *Monitor dressing to ensure it is intact and adhering. Report lose [sic] dressing to treatment nurse. *Monitor nutritional status. Serve diet as ordered, monitor intake and record. *Monitor/ document/ report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size .*

The resident requires air flotation pressure redistribution device. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate .

Resident R44's documentation on facility's Pressure Injury (PI) Weekly Tracker is as follows:

12/16/24: .Location: Coccyx Type: Pressure. Length 0.9cm Width 0.8cm Depth 0.3cm stage 2. 5. Tissue type: 5c. Granulation 50% 5d. Slough 50%. 6. Drainage b. Serous 7. Amount of drainage b. Light .B. Plan/ Treatment .6. Turn and reposition every 2 hours .

Resident R44 was admitted with a PI that was 50% slough, which would indicate it's at least a stage 3.

12/18/24: . Length 1.1cm Width 0.8cm Depth 0.3cm stage 3. 5. Tissue type: 5c. Granulation 20% 5d. Slough 80%. 6. Drainage b. Serous 7. Amount of drainage c. moderate .B. Plan/ Treatment .6. Turn and reposition every 2 hours- Cleanse with wound cleanse [sic], apply medihoney to wound bed, cover with bordered foam dressing. Skin prep to periwound daily x 30 days. Surgical excisional debridement performed to remove necrotic tissue and establish viable tissue .

It is important to note that there were no wound measurements from 12/18/24-1/8/25, during which time Resident R44's PI increased in size.

1/8/25: .Length 4.1cm Width 0.5cm Depth 0.1cm stage 3. 5. Tissue type: 5a. Skin 50% 5c. Granulation 10% 5d. Slough 40%. 6. Drainage b. Serous 7. Amount of drainage c. moderate .B. Plan/Treatment .6. Turn and reposition every 2 hours- Cleanse with wound cleanse [sic], apply medihoney to wound bed, cover with bordered foam dressing. Skin prep to periwound daily x 30 days. Surgical excisional debridement performed to remove necrotic tissue and establish viable tissue .

1/15/25: 1/8/24: . Length 3.5cm Width 1.8cm Depth 0.6cm stage 3 . 5. Tissue type: 5a. Skin 80% .5d. Slough 10%. 6. Drainage b. Serous 7. Amount of drainage b. moderate .B. Plan/Treatment .6. Turn and reposition every 2 hours- Cleanse with wound cleanser. Skin prep periwound apply 3x/weekly. Lightly pack wound using iodoform 1/4 3x/week (leaving a tail) and cover with duoderm. Surgical excisional debridement performed to remove necrotic [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49436

Residents Affected - Many Based on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R). This has the potential to affect all 68 residents residing at the facility.

Surveyors entered on the weekend due to the facility triggering for low weekend staffing.

NHA A (Nursing Home Administrator) indicated the schedule is based on the census and hours per patient day (HPPD), which does not take into consideration the acuity of the facility's resident population.

Residents in Resident Council voiced concerns that staff take too long to answer call lights and meal trays on

the halls are not passed timely due to staff not being available.

Resident R56 voiced concerns about long wait times when wanting to get up.

Staff stated there are care items they cannot complete for residents due to having low staffing.

This is evidenced by:

The Facility Assessment Tool, date 1/3/25, states in part: Staffing plan: RN/LPN/LVN (Registered Nurse / Licensed Practical Nurse / Licensed Vocational Nurse) 1.5:40 RN/LPN Days, 1.5:40 RN/LPN Evenings. Direct care staff 1:13 ratio CNA (Certified Nursing Assistant) Days, 1:13 ratio CNA Evenings, 1:26 ration CNA Nights. Staff Hours on Average: RN Hours: .5, CNA Hours: 1.6, Total Nursing Staff Hours: 3.0

HPPD (Hours per patient day) is used to measure the amount of time for care each resident receives in a 24 hour period. HPPD is calculated using the following equation: total nursing hours divided by the number of residents.

Example 1

On Sunday, February 16, 2025, surveyors entered the building for the facility's annual recertification survey. Surveyors entered on a weekend due to the facility triggering for low weekend staffing.

Example 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0725 On 2/19/25 at 8:39 AM, Surveyor interviewed NHA A regarding the facility staffing. NHA A indicated he actively participates in the scheduling of the facility. NHA A stated the facility staffs according to the census, Level of Harm - Minimal harm or if the census goes up then the facility staffs more CNAs and if the census goes down then the facility will potential for actual harm schedule less CNAs. NHA A stated the ideal schedule would be 3.0 HPPD. NHA A indicated during the all-staff monthly meetings, the staff have voiced it would be beneficial to have more staff scheduled. NHA Residents Affected - Many indicated during resident council, residents have voiced concerns about low staffing levels.

The facility census postings were reviewed for the dates 2/2/25 through 2/19/25 for HPPD, as follows:

2/2/25 was 2.6 HPPD (Sunday)

2/3/25 was 2.6 HPPD

2/4/25 was 2.5 HPPD

2/5/25 was 2.8 HPPD

2/6/25 was 2.6 HPPD

2/7/25 was 2.7 HPPD

2/8/25 was 2.9 HPPD (Saturday)

2/9/25 was 2.9 HPPD (Sunday)

2/10/25 was 2.5 HPPD

2/11/25 was 2.5 HPPD

2/12/25 was 3.2 HPPD

2/13/25 was 2.7 HPPD

2/14/25 was 2.3 HPPD

2/15/25 was 2.4 HPPD (Saturday)

2/16/25 was 2.7 HPPD (Sunday)

2/17/25 was 2.7 HPPD

2/18/25 was 2.6 HPPD

2/19/25 was 2.8 HPPD

Of note, only one day (2/12/25) was at or above 3.0 HPPD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0725 Example 3

Level of Harm - Minimal harm or Resident council minutes were reviewed. potential for actual harm November 2024 resident council minutes state in part: 2nd shift can sometimes take too long to answer a call Residents Affected - Many light .

December 2024 resident council minute state in part: Residents voiced concerns for Hall trays not being passed timely, resulting in food that isn't as warm as they'd like. Resident stated that they understand that sometimes someone needs assistance when trays come but that someone should help to avoid food temps.

On 2/19/25 at 12:30 PM, Surveyor interviewed NHA A regarding resident council concerns about staffing. NHA A stated residents in resident council have mentioned concerns with staffing but it is not a continual common theme.

Example 4

Resident R56 admitted to the facility on [DATE REDACTED] with diagnoses including arthritis (joint inflammation).

Resident R56's comprehensive assessment, dated 1/5/25, indicates Resident R56 is dependent on staff for toileting, personal hygiene, and requires 2 staff for transferring between surfaces.

On 2/16/25 at 12:13 PM, Surveyor interviewed Resident R56 about call light response time. Resident R56 stated when he turns

on his call light, staff will come in and turn it off and tell him they need to get a second person. Resident R56 states it will take them 20 minutes or longer before they come back. Resident R56 states he will sometimes turn his light back

on if it takes too long for them to return.

On 2/19/25 at 9:34 AM, Surveyor interviewed CNA E (certified nursing assistant) regarding call light response times. CNA E indicated call lights will be on for longer than 20 minutes at times. CNA E indicated

she will go into a resident's room, turn off the call light without meeting the resident's needs and tell the resident she will be back.

Example 5

On 2/19/25 at 9:20 AM, Surveyor interviewed LPN N (Licensed Practical Nurse) regarding staffing. LPN N indicated she does not perform any CNA duties when working because she does not have time to help.

On 2/19/25 at 9:23 AM, Surveyor interviewed MT M (Med Tech, a CNA that can administer medications) regarding staffing. MT M indicated she does not perform any CNA duties when she is working as a med tech but will occasionally answer a resident's call light if she has time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0725 On 2/19/25 at 9:24 AM, Surveyor interviewed CNA E regarding staffing. CNA E is employed full time at the facility. Surveyor asked CNA E to think about the last 2 weeks she has worked and to recall a time when she Level of Harm - Minimal harm or received help from ancillary staff or the nurses. CNA E indicated she has not received help from other staff or potential for actual harm the nurses when completing her CNA duties. CNA E indicated she cannot complete all the resident's care, due to low staffing. CNA E indicated she cannot always get to things like resident's oral care. CNA E Residents Affected - Many indicated resident call light response time can be longer than 20 minutes at times due to low staffing.

On 2/19/25 at 9:38 AM, Surveyor interviewed CNA CC regarding staffing. CNA CC indicated he can't get it all done when questioned about completing resident care. CNA CC indicated he cannot complete things like range of motion or oral care for residents. CNA CC states he must prioritize things like changing incontinent residents over providing oral care.

On 2/19/25 at 12:30 PM, Surveyor interviewed NHA A regarding low staffing. NHA A indicated multiple department heads are [NAME] certified and can work as a CNA but it is rarely required.

44552

Example 6

On 2/16/25 Surveyor observed lunch starting down D hallway at 12:10 PM. Most residents down D hallway eat in the common/living room area down D hallway. Surveyor observed no staff in common area on two separate times during lunch time. Surveyor observed no staff from 12:20PM-12:32PM and again at 12:40PM-12:51PM. Multiple residents require supervision and assistance during meals. Surveyor observed Resident R38 struggling with her meal. Surveyor observed Resident R38 attempting to raise her spoon up five times and was unable to get her spoon all the way up to her mouth. Resident R38 asked Surveyor if Surveyor could help her eat her meal.

Example 7

On 2/16/25 at 12:30 PM, CNA Z (certified nursing assistant) indicated it is usually just one staff down D hall

on the weekends. CNA Z indicated it depends on the weekend if there is an activity aid at the facility. CNA Z indicated there are times she can not get all the tasks done due to the staffing ratio. CNA Z indicated there is supposed to be a float CNA that works all hallways. CNA Z indicated staff is not quick to respond when asking for help over the walkie talkie. CNA Z indicated there are times that the float CNA is helping someone else, on break, or the position didn't get filled that day.

Example 8

Resident R38 was admitted to the facility on [DATE REDACTED]. Resident R38's Minimum Data Set, dated dated dated [DATE REDACTED] indicates Resident R38 has a brief interview of mental status score of 08 out of 15, indicating Resident R38 is moderately cognitively impaired.

On 2/16/25 at 2:18 PM, Resident R38 indicated she needs assistance with eating meals. Surveyor asked Resident R38 if the CNA often got pulled to answer call lights or help others during mealtime? Resident R38 stated yes. Surveyor asked if Resident R38 often waits for assistance to eat? Resident R38 indicated yes. Resident R38 indicated staffing is a concern and there is often not enough staff down Resident R38's hallway.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0725 Example 9

Level of Harm - Minimal harm or On 2/16/25 at 2:45 PM, CNA AA indicated it is common that there is only one CNA down D hallway. CNA AA potential for actual harm indicated staffing is a concern.

Residents Affected - Many Example 10:

On 2/17/25 at 2:18 PM, CNA BB (certified nursing assistant) indicated staffing is a concern. CNA BB indicated there is often one CNA down D hallway and with the population they serve down D hallway it gets very chaotic. There are not activity aides or any activities during the weekends. CNA BB indicated the activities are not geared for residents with dementia. CNA BB indicated she has voiced these concerns, and nothing changed. CNA BB indicated more activities would benefit everyone down D hallway. CNA BB indicated there are times she can't get to everyone at the end of the shift to assist with repositioning and going to the bathroom. CNA BB indicated the float is not usually down D hallway and recently two minors were working on A hallway alone and neither of them can use the Hoyer lift. CNA BB indicated she is often very rushed, and the residents can feel that.

50285

Example 11:

Resident R12 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Muscle Weakness, Type 2 Diabetes Mellitus, Emphysema Unspecified (a chronic lung disease that makes it difficult to breathe), Major Depressive Disorder, and Chronic Pain.

Resident R12's MDS (Minimum Data Set) with a target date of 2/10/25, indicates, in part: BIMS (Brief Interview of Mental Status) score of 14 out of 15, indicating Resident R12 is cognitively intact.

Resident R12's Care Plan, dated 1/16/25, states, in part: Focus: ADL (Activities of Daily Living) self-care deficit as evidenced by: total assist related to: progressive generalized weakness, severe . Goal: Will receive assistance to meet ADL needs . Interventions: Bed Mobility: Assist of 2 for bed mobility able to reposition self slightly . Dressing: Requires extensive assist of 1 staff to dress . Locomotion: requires total assist with locomotion . Personal Hygiene: Assist of 1 to wash own face and hands . Toileting: Assist of 2 using bedside commode and use of shower sling for transfers. Generally continent of bowel, occasionally incontinent of bladder . Transfer: Assist of 2 staff and use of mechanical lift .

On 2/16/25 at 10:18 AM, Surveyor interviewed Resident R12, who stated, the people work very hard here, but they don't have enough staff. Resident R12 indicated that he has had to wait a long time for staff assistance. Resident R12 stated that last night he waited a half hour to use the commode, but that sometimes it is over an hour. Resident R12 indicated that the staff have to use the Hoyer lift to get him to the commode, and that sometimes they can't find anyone to help, so that he has to wait longer. Resident R12 stated that it was very difficult to wait that long to go to the bathroom, and that he felt, like I'm not very important.

Example 12:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0725 Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Alzheimer's Disease with late onset, Dementia in other diseases classified elsewhere, moderate, and Major Depressive Disorder. Level of Harm - Minimal harm or potential for actual harm Resident R1's admission MDS with a date of 11/25/24, indicates, in part: a BIMS score of 9 out of 15, indicating Resident R1 has moderate cognitive impairment. Residents Affected - Many Resident R1's Care Plan, dated 2/15/21, states, in part: Focus: ADL self-care deficit related to: physical limitation, dementia with behaviors . Goal: Will be clean, dressed and well groomed daily to promote dignity and psychosocial wellbeing . Interventions: Ambulation: [Resident Name] is non ambulatory at this time . Bathing: [Resident Name] requires extensive to near total assist with showering . Bed Mobility: [Resident Name] requires extensive assist of 1 staff with repositioning . Dressing: [Resident Name] requires extensive assist of 1 staff for dressing . Eating: [Resident Name] requires set up assist with meals . Locomotion: [Resident Name] requires extensive assist of 1 staff for locomotion in wheelchair . Personal Hygiene: [Resident Name] requires extensive assist with personal hygiene . Toileting: [Resident Name] requires extensive assist of one staff with toileting and is frequently incontinent of bladder and bowel . Transfers: [Resident Name] requires extensive assist with transfers with 2 staff and use of EZ-stand .

On 2/16/25 at 10:52 AM, Surveyor interviewed Resident R1, who stated that sometimes she has to wait an hour for her call light to be answered. Resident R1 stated that it makes her feel anxious to wait that long to have to use the bathroom, as she is unable to do it by herself.

Example 13:

Resident R316 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Weakness, Hemiplegia (a neurological condition that causes paralysis or weakness on one side of the body), Hemiparesis (one-sided muscle weakness), and Personal History of Urinary Tract Infections.

Resident R316's Care Plan, dated 2/12/25, states, in part: Focus: ADL self-care deficit as evidenced by: right sided deficit/weakness related to: stroke . Goal: Will improve current level of function in ADLs (activities of daily living) through the review date . Interventions: Ambulation/Locomotion: with device wheelchair . Bathing/Showering: Assist of 1 staff . Personal Hygiene: Assist of 1 staff . Toileting: Assist of 1 staff . Transfer: Assist of 2. Transfer with EZ-stand for all transfers with 2 staff .

On 2/16/25 at 10:28 AM, Surveyor interviewed Resident R316, who indicated that usually he has to wait a long time for his call light to be answered. Resident R316 stated that he requires assistance from staff to get up and then to lay back down, and that he had to wait a half hour this morning. Resident R316 stated he felt extremely frustrated having to just sit and wait, and that at times they are so short staffed he has to wait an hour.

Example 14:

Resident R15 was admitted to the facility on [DATE REDACTED] with diagnosis that include, in part: Seizures, Contracture of Muscles, multiple sites, Weakness, and Unspecified Atrial Fibrillation (a common heart rhythm disorder where the upper chambers of the heartbeat irregularly and rapidly).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 45 525452 Department of Health & Human Services Printed: 09/07/2025 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 525452 B. Wing 03/03/2025

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

Elroy Health Services 307 Royall Ave Elroy, WI 53929

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 0725 Resident R15's admission MDS with a date of 1/21/25, indicates, in part: a BIMS score of 13 out of 15, indicating Resident R15 is cognitively intact. Level of Harm - Minimal harm or potential for actual harm Resident R15's Care Plan, dated 7/15/24, states, in part: Focus: ADL self-care deficit as evidenced by: need for staff assist . Goal: Will improve current level of function in ADLs through the review date . Interventions: Residents Affected - Many Ambulation/Locomotion: [Resident Name] is non-ambulatory at this time. Requires extensive assist with locomotion . Bathing/Showering: Assist of 1 to shower or bathe . Bed Mobility: Requires assist of 1 for bed mobility . Dressing: Assist of 1 for dressing . Personal Hygiene: Assist of 1 to set up and encourage her to wash her own face and hands . Toileting: Assist of 1 for toileting. Continent of both bowel and bladder with occasional episodes of bladder incontinence . Transfer: Transfer with 1 staff, walker and gait belt .

On 2/16/25 at 10:36 AM, Surveyor interviewed Resident R15, who indicated that call lights are not answered right away, sometimes she has to wait because the staff are busy. Resident R15 indicated she did not know how long she has to wait, but at times it can be quite long. Resident R15 stated she is angry when she has to wait to go to the bathroom and she sometimes has accidents if she has to wait too long due to their not being enough staff.

Example 15:

On 2/16/25 at 2:13 PM, Surveyor interviewed Staff Member F, who wished to remain anonymous. Staff Member F told Surveyor that she does not feel like there is enough staff to meet the residents needs. Staff Member F stated that sometimes she is scheduled to work A wing by herself with over 20 residents to care for, and that she doesn't feel like that is safe. Staff Member F indicated that when they are short staffed, they are not able to get resident's showers completed, do oral cares, or toilet and reposition every two hours. Staff Member F stated that this happens frequently.

Example 16:

On 2/18/25 at 10:57 AM, Surveyor interviewed CNA E who stated that they are short staffed a couple times a week, mostly on PM shift. CNA E stated that when they don't have enough staff they can't get to toileting or repositioning the residents frequently enough.

Cross Reference: