Florence Health Services

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R4 argued with each other and slammed into each other. Resident R4 indicated Resident R3 was the initial aggressor. Resident R4 indicated the facility moved Resident R3 out of their shared room after the incident. (The facility's census indicated Resident R3 moved into the room with Resident R4 room on 9/10/25. Resident R3 moved out of the room on 9/12/25 and moved into a room that shared a bathroom with Resident R2.)The resident-to-resident altercation between Resident R3 and Resident R4 was not investigated by the facility or reported to the SA.On 10/7/25, Surveyor reviewed a facility-reported incident that indicated on 9/13/25, Resident R3 entered Resident R2's room and slapped Resident R2 in the face multiple times. The facility investigated the incident and reported the incident to the SA.On 10/7/25, Surveyor reviewed Resident R2's medical record. Resident R2 was admitted to the facility on [DATE REDACTED] and had diagnoses including chronic obstructive pulmonary disease (COPD), alcoholic cirrhosis of liver with ascites, type 2 diabetes, and respiratory failure with hypoxia. Resident R2's most recent MDS assessment, dated 7/1/25, had a BIMS score of 15 out of 15 which indicated Resident R2 had intact cognition. On 10/8/25 at 2:39 PM, Surveyor interviewed Unit Manager (UM)-H who was not aware of the physical aggression that occurred between Resident R3 and Resident R4 on 9/11/25. UM-H indicated verbal and physical aggression between Resident R3 and Resident R4 should have been investigated and reported per the facility's policy. UM-H understood how not addressing the incident on 9/11/25 between Resident R3 and Resident R4 could lead to a lack of protection for Resident R2 during the altercation between Resident R2 and Resident R3 on 9/13/25. UM-H oversaw risk management for the facility since August of 2025 and indicated if interventions were implemented and Resident R3's care plan was updated after the 9/11/25 altercation with Resident R4, the 9/13/25 incident with Resident R2 may not have occurred.On 10/8/25 at 4:05 PM, Surveyor interviewed Director of Nursing (DON)-B who wasn't aware of

the extent of the resident-to-resident altercation between Resident R3 and Resident R4 on 9/11/25 and verified an investigation was not completed. DON-B indicated Resident R3's care plan should have been updated to address verbal and physical aggression and follow-up should have been completed on Resident R4's care plan to ensure Resident R4 had appropriate support. DON-B would not say with certainty that thoroughly investigating the 9/11/25 altercation would have prevented aggression toward Resident R2 on 9/14/25, but verified Resident R3's verbal and physical aggression should have been addressed. DON-B indicated Resident R3's care plan should have been updated right away and the team should have been notified of the change so future abuse could be prevented.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Florence Health Services

5778 Chapin St Florence, WI 54121

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

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

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 2 residents (R) (Resident R3 and Resident R4) of 5 sampled residents. On 9/11/25, an altercation occurred between Resident R3 and Resident R4 that involved verbal and physical aggression. The facility did not report the allegation of abuse to the SA. Findings include:The facility's Abuse, Neglect and Exploitation policy, with a revised date of 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written .VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services (APS), and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .B. The Administrator will follow up with government agencies to report the results of the investigation when final within five working days of the incident, as required by state agencies.On 10/7/25, Surveyor reviewed Resident R3's medical record. Resident R3 was admitted to the facility on [DATE REDACTED] and had diagnoses including dementia with behavioral disturbance and psychotic disturbance, anxiety, and repeated falls. Resident R3's most recent Minimum Data Set (MDS) assessment, dated 8/21/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated Resident R3 had moderate cognitive impairment. Resident R3 had an activated Power of Attorney (POA) for healthcare decision making.A progress note, dated 9/11/25 at 9:24 PM, indicated Resident R3 was in bed but attempted to take Resident R3's roommate's (Resident R4) soda which resulted in verbal and physical aggression that involved yelling, swearing, threatening, and pushing a wheelchair and walker against each other.On 10/8/25 at 3:33 PM, Surveyor interviewed Resident R3 who did not recall the altercation with Resident R4 and indicated nobody would live through it if they were aggressive with Resident R3.On 10/8/25, Surveyor reviewed Resident R4's medical record. Resident R4 was admitted to the facility on [DATE REDACTED] and had diagnoses including cerebral infarction, cognitive communication deficit, and depression. Resident R4's most recent MDS assessment, dated 9/26/25, had a BIMS score of 9 out of 15 which indicated Resident R4 had moderate cognitive impairment. On 10/8/25 at 3:39 PM, Surveyor interviewed Resident R4 who indicated Resident R3 and Resident R4 had an argument and slammed into each other. Resident R4 indicated Resident R3 was the initial aggressor and was moved out of the room after the incident.On 10/8/25, Surveyor requested a copy of the facility's report to the SA.On 10/8/25 at 4:05 PM, Surveyor interviewed Director of Nursing (DON)-B who wasn't aware of the extent of the resident-to-resident altercation between Resident R3 and Resident R4 and stated the altercation was not reported to the SA. DON-B indicated the facility takes incidents of abuse seriously and verified the resident-to-resident altercation should have been reported to the SA.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Florence Health Services

5778 Chapin St Florence, WI 54121

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

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

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview and record review, the facility did not thoroughly investigate a resident-to-resident altercation for 2 residents (R) (Resident R3 and Resident R4) of 5 sampled residents. On 9/11/25, a resident-to-resident altercation occurred between Resident R3 and Resident R4 that involved verbal and physical aggression.

The facility did not thoroughly investigate the altercation. Findings include:The facility's Abuse, Neglect and Exploitation policy, with a revised date of 7/15/22, indicates: .2. The facility will designate a leadership position in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to ensure its policies are implemented as written .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when allegation or suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur .On 10/7/25, Surveyor reviewed Resident R3's medical record. Resident R3 was admitted to the facility on [DATE REDACTED] and had diagnoses including dementia with behavioral disturbance and psychotic disturbance, anxiety, and repeated falls. Resident R3's most recent Minimum Data Set (MDS) assessment, dated 8/21/25, had a Brief

Interview for Mental Status (BIMS) score of 10 out of 15 which indicated Resident R3 had moderate cognitive impairment. Resident R3 had an activated Power of Attorney (POA) for healthcare decision making.A progress note, dated 9/11/25 at 9:24 PM, indicated Resident R3 was in bed but attempted to take Resident R3's roommate's (Resident R4) soda which resulted in a verbal and physical altercation that involved yelling, swearing, threatening, and pushing a wheelchair and walker against each other.On 10/8/25 at 3:33 PM, Surveyor interviewed Resident R3 who did not recall an altercation with Resident R4 and indicated nobody would live through it if they were aggressive with Resident R3.On 10/8/25, Surveyor reviewed Resident R4's medical record. Resident R4 was admitted to the facility on [DATE REDACTED] and had diagnoses including cerebral infarction, cognitive communication deficit, and depression. Resident R4's most recent MDS assessment, dated 9/26/25, had a BIMS score of 9 out of 15 which indicated Resident R4 had moderate cognitive impairment. On 10/8/25 at 3:39 PM, Surveyor interviewed Resident R4 who indicated Resident R3 and Resident R4 had an argument and slammed into each other. Resident R4 indicated Resident R3 was the initial aggressor and was moved out of

the room after the incident.On 10/8/25, Surveyor requested the facility's investigation for the resident-to-resident altercation. On 10/8/25 at 4:05 PM, Surveyor interviewed Director of Nursing (DON)-B who wasn't aware of the extent of the resident-to-resident altercation between Resident R3 and Resident R4 and indicated the facility did not have an investigation for the incident. DON-B indicated the facility takes incidents of abuse seriously and verified the resident-to-resident altercation should have been thoroughly investigated.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Florence Health Services

5778 Chapin St Florence, WI 54121

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

traumatic stress disorder (PTSD) it should be reflected on the resident's diagnoses list and MDS assessment. LPN-C indicated residents should have personalized care plans which include specific triggers and interventions for prevention. LPN-C was not aware that Resident R2 had trauma or triggers. LPN-C reviewed Resident R2's trauma care plan and indicated staff would be unable to care for Resident R2 because there were no specifics listed related to trauma care.On 10/8/25 between 2:00 PM and 4:00 PM, Surveyor interviewed Social Services Coordinator (SSC)-K who indicated if a resident has trauma or PTSD it should be on their diagnoses list. SSC-K indicated residents with trauma should have a care plan that includes triggers and interventions related to the trauma. SSC-K indicated care plans should be personalized to each resident's specific triggers and trauma needs. SSC-K was not aware that Resident R2 had trauma and a care plan that was not specific. When Surveyor showed SSC-K Resident R2's Trauma-Informed Care Observation quarterly assessments from 7/1/25 and 9/29/25 that contained SSC-K's signature, SSC-K indicated SSC-K was new to the role and should have edited the interventions to indicate Resident R2's specific trauma and triggers.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Florence Health Services

5778 Chapin St Florence, WI 54121

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10/7/25 at 4:19 PM, Surveyor interviewed Pharmacist (PH)-F who stated the pharmacy reviews orders that are faxed. PH-F indicated the pharmacy does not review every medication to ensure the order is entered correctly unless the medication appears to be off. PH-F indicated the sliding scale order should be entered by the facility and stated the best practice is to have blood sugar checks ordered before meals to ensure

the insulin is working properly.On 10/8/25 at 8:57 AM, Surveyor interviewed RN-G who was unsure why Resident R1's MAR contained only one daily blood sugar check. RN-G reviewed Resident R1's hospital discharge summary and confirmed there was a sliding scale insulin order in the summary. RN-G stated the sliding scale is an order and RN-G would have clarified the sliding scale if RN-G had transcribed the orders. RN-G indicated discharge summaries should be read thoroughly and discrepancies should be clarified with the discharge hospitalist. RN-G indicated even if Resident R1 was on scheduled short acting insulin, Resident R1's blood sugar should be checked prior to meals and insulin should be administered per the sliding scale. On 10/8/25 at 2:43 PM, Surveyor interviewed DON-B who indicated the sliding scale was not part of Resident R1's medication orders but should have been clarified. When Surveyor asked if Resident R1's blood sugar should have been monitored prior to meals, DON-B indicated Resident R1 saw the provider the day after admission and the facility's policy is to follow provider orders. DON-B indicated the provider does not work with electronic health records and gives verbal orders to nurses who dictate and put the order in the provider's facility mailbox to be signed. DON-B stated DON-B is working on a new admission process as of 10/8/25 and will be auditing blood sugar checks and insulins. DON-B indicated the facility does not have a process for a second nurse to double check the admission nurse's discharge summary order transcription and stated staff are trusted to double check.

DON-B confirmed staff could have verified the sliding scale for Resident R1 with the discharge provider.

Event ID:

Facility ID:

If continuation sheet