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F-F700). The facility did not complete a thorough fall investigation, determine a root cause for his fall, complete reassessments to determine if bed rails continue to be appropriate for Resident R8, and create a care plan with interventions in a timely manner.

Findings include:

The facility's Fall Risk Assessment that is not dated, documents:

Each resident will be assessed for the risks of falling and will receive care and services in accordance with

the level of risk to minimize the likelihood of falls.

1. The facility utilizes a standardized risk assessment for determining fall risk. The risk assessment categorizes residents as a high risk with a score of 10 or greater. The risk assessment will be completed upon admission, quarterly, or when a significant change is identified.

2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk.

3. The nurse will initiate interventions on the resident's baseline care plan if the resident indicates high risk.

4. Each resident's risk factors, and environmental hazards will be evaluated when developing the residents comprehensive plan of care.

5. When any resident experiences a fall, the facility will:

Assess the resident.

Complete an event documentation report.

Complete a fall risk assessment.

Notify physician and family.

Review the residence care plan and update as indicated.

Document all assessments and actions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 525549 Department of Health & Human Services Printed: 09/11/2025 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 525549 B. Wing 01/08/2025

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

Heritage Square Health Care Center 5404 W Loomis Rd Greendale, WI 53129

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

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

F 0689 If a fall is witnessed, obtain witness statement.

Level of Harm - Minimal harm or Resident R8 is a [AGE] year-old resident who was admitted to the facility on [DATE REDACTED]. Resident R8's diagnoses include muscle potential for actual harm wasting and atrophy, epilepsy, dysphagia, abnormalities in gait and mobility, dementia, adult failure to thrive, and peripheral vascular disease. Residents Affected - Few Resident R8's Admission Minimum Data Set (MDS) completed on 12/1/24 documents that Resident R8 is dependent with rolling left to right, chair and bed transfers, and shower/tub transfers. Resident R8's MDS documents no falls in the last month prior to admission. Resident R8's MDS documents no bed rail in use. Resident R8 was documented as having a Brief

Interview for Mental Status (BIMS) score of 15 indicating Resident R8 is cognitively intact.

Resident R8's care plan, dated 11/27/24, documents:

A physical functioning deficit related to mobility impairment and self-care impairment (date initiated 11/29/24).

Interventions include:

(Resident R8) requires a Hoyer lift with assistance of two for transfers (date initiated 11/29/24).

(Resident R8) requires total assistance for bed mobility (date initiated 11/29/24).

(Resident R8) is at risk for falls related to new environment (date initiated 12/4/24).

Interventions include:

Call light and personal items available and in reach or provider reacher (date initiated 12/8/24).

Keep environment well lit and free of clutter (date initiated 12/8/24).

Keep personal items within reach (date initiated 12/8/24).

(Resident R8) experienced a fall from bed (date initiated 12/22/24).

Interventions include:

Bed in low position (date initiated 12/22/24).

Call light within reach (date initiated 12/22/24).

Educate staff on proper linen for air mattress. Staff to continue toilet program every two to three hours and as needed (date initiated 12/22/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 525549 Department of Health & Human Services Printed: 09/11/2025 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 525549 B. Wing 01/08/2025

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

Heritage Square Health Care Center 5404 W Loomis Rd Greendale, WI 53129

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

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

F 0689 Surveyor reviewed the facility fall investigation dated 12/22/24 for Resident R8. The fall investigation documents Licensed Practical Nurse (LPN)- I was called into Resident R8's room on 12/22/24 at 6:50 am. Resident R8 was observed to be Level of Harm - Minimal harm or in a sitting position leaning against the enable bars. Resident R8 appeared to have slid out of bed and was noted on potential for actual harm the air mattress. Resident R8 was last checked and changed on 12/22/24 at 4:45 am. Resident R8 was wrapped in sheets and staff lowered Resident R8 to the floor for safety. Resident R8 was assessed and Hoyer lifted back to bed. Resident R8's call light was Residents Affected - Few attached to his bed linen. Resident R8 stated he was trying to contact staff and stated he did not know where his call light was. The facility fall investigation indicates Resident R8's Power of Attorney (POA) and provider were notified on 12/22/24 of Resident R8's fall. Predisposing environmental factors identified furniture. Predisposing situation factors were identified as ambulating without assistance and responding to toileting needs. Staff statements were obtained, and the Interdisciplinary Team (IDT) met which states an interview was obtained from Resident R8 who indicates he was beginning to fall, and he put his arm through the side rail in an attempt to prevent the fall. A post fall intervention of toileting every 2-3 hours was determined after the IDT met on 12/22/24.

Surveyor noted the facility fall investigation does not state whether the call light was within reach of Resident R8 at the time of the fall. Surveyor also noted discrepancies with the position of how Resident R8 was discovered after the fall. Initially the fall investigation noted Resident R8 being found in a sitting position leaning against the enabler bars but later states Resident R8 was lowered to the floor by facility staff. Surveyor notes there is no mention of Resident R8 having his arm stuck in the bed rail in the incident description which is documented in a facility progress note dated 12/22/24 and Resident R8 provided a statement in an interview stating his arm was stuck in the bed rail. Surveyor notes the root cause is not clearly identified and investigated in the fall investigation.

On 1/6/25, at 10:42 am, Resident R8 was observed in bed unattended with assist bed rails observed on both sides of

the bed.

On 1/7/25, 8:32 am, Resident R8 was observed in bed unattended with assist bed rails observed on both sides of the bed.

On 1/7/25, at 9:16 am, Surveyor interviewed Resident R8 who states he had his left arm stuck in his bed rail recently. Resident R8 denies pain or injury. Surveyor asked Resident R8 what happened and Resident R8 stated he was unsure how it happened, but his left arm got stuck in his bed rail, so he put himself on the floor to help get his arm out of the bed rail. Resident R8 denies any further incidents with his bed rails and states he hangs on to them when staff are providing cares.

On 1/7/25, at 10:07 am, Surveyor interviewed Director of Therapy (DOT)- G who states therapy does an initial assessment with each resident which also includes an assessment to determine bed rail needs. DOT- G indicates therapy starts the assessment and nursing completes and signs off on the assessment if the resident passed the bed rail assessment. Therapy then notifies maintenance to place the bed rails. Surveyor asked DOT- G if a bed rail assessment should be completed prior to bed rails being applied to the resident's bed and DOT- G stated yes, an assessment is required prior to any bed rails being placed on a resident's bed. Surveyor asked DOT- G what she would expect if a resident has an incident or injury related to a bed rail. DOT- G states she would expect the handrails to be removed and re-evaluated. DOT- G states it makes her wonder if the resident had a decline in function or other determining factors that may have contributed to

an incident involving a bed rail. Surveyor asked DOT- G if she was aware of Resident R8 having his arm stuck in his bed rail on 12/22/24. DOT- G replied she was not aware of Resident R8 having any incidents with his bed rail. DOT- G acknowledged Resident R8 still having bed rails currently on his bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 525549 Department of Health & Human Services Printed: 09/11/2025 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 525549 B. Wing 01/08/2025

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

Heritage Square Health Care Center 5404 W Loomis Rd Greendale, WI 53129

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

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

F 0689 On 1/7/25, at 12:59 am, DOT- G notified Surveyor, therapy was notified that Resident R8 had moved from bed A to bed B in his room and the bed rails were already present on bed B. Nursing staff then notified therapy of bed Level of Harm - Minimal harm or rails being on Resident R8's bed on 12/23/24 and requested a bed rail assessment to be completed by therapy. DOT- potential for actual harm G states she was aware of Resident R8 having a fall but was not aware of Resident R8 having his arm stuck. DOT- G indicates Resident R8 braced himself while sliding out of bed and the nurse popped the bed rail off the bed to get Resident R8's arm out. Residents Affected - Few Surveyor then asked if therapy would complete another bed rail assessment and DOT- G stated no, therapy determined Resident R8 was safe for bed rails on 12/23/24. DOT- G states Resident R8 was using his bed rail to prop himself and lowered himself down. DOT- G indicates the next bed rail assessment would be completed quarterly or by nursing requests.

On 1/7/25, at 1:43 pm, Surveyor interviewed Licensed Practical Nurse (LPN)- I who states the Certified Nursing Assistant (CNA) notified her that Resident R8 was sliding to the floor and nursing staff assisted him to the floor. LPN- I indicates when she entered Resident R8's room, she found Resident R8 with his buttocks off the bed with his left arm hanging in the bedrail. Nursing staff lowered the resident to the floor, and she was able to take off the bed rail by unscrewing it. LPN- I indicates Resident R8 did not sustain any injury or pain and that Resident R8 was attempting to sit on the side of the bed and use the bathroom. LPN- I states she contacted (name of telehealth provider)who was the provider on call and placed the device on the side table for the provider to view Resident R8's position. LPN- I states it was determined the wrong bed linen was used with the mattress and bed rail. LPN- I indicates a fitted sheet can make the mattress deflate and areas of imbalance can occur. LPN- I states Resident R8's care plan was updated to indicate Resident R8 requires a flat sheet. LPN- I then stated Resident R8 is independent and will use his grab bar to move side to side independently.

On 1/8/25, at 9:15 am, Surveyor observed Resident R8 during wound care. Surveyor asked Resident R8 if he was able to grab his bed rails to roll himself side to side, Resident R8 stated, not by himself. Resident R8 required assistance by staff to grab on to the bed rail to roll himself on his side.

On 1/7/25, at 1:40 pm, Surveyor interviewed Certified Nursing Assistant (CNA)- J who indicated she is familiar with Resident R8 and works with him often. CNA- J states Resident R8 is unable to roll himself side to side independently. CNA- J indicates staff will roll Resident R8 to his side and Resident R8 will then hang on to the bed rail during cares.

On 1/7/25, at 3:03 pm, at end of day meeting, Surveyor shared information above with Nursing Home Administrator (NHA)- A and Director of Nursing (DON)- B. DON-B stated facility staff did not lower Resident R8 to the floor and Resident R8's arm was through the bed rail and was not stuck. Surveyor reviewed the facility progress note dated 12/22/24 which documents Resident R8 having his left arm stuck in the bed rail. DON- B again stated Resident R8's arm was not stuck and was through the bed rail but not stuck in the bed rail. Surveyor shared concerns with NHA-

A and DON- B with the facility not having a thorough investigation, discrepancies with statements, interviews, and investigations identifying a thorough root cause analysis. NHA- A and DON- B acknowledge and shared no additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 525549 Department of Health & Human Services Printed: 09/11/2025 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 525549 B. Wing 01/08/2025

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

Heritage Square Health Care Center 5404 W Loomis Rd Greendale, WI 53129

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

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

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48391 Residents Affected - Few Based on observation, interview and record review, the facility did not assess the risk of entrapment and

review the risks and benefits for 1 (Resident R8) of 1 residents observed having bed rails.

Resident R8, who is dependent on staff for mobility, was observed to have a half side rail/grab bars on both sides of

the bed and did not have a completed side rail risk assessment.

Findings include:

The facility's Bed Rail Policy dated 10/1/22, documents it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the bed rails. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of bed rails meet those needs. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives fail to meet the resident's assessed needs. The resident assessment must also assess the residence risk from using bedrail's. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in

the bed rail itself. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. Responsibilities of ongoing monitoring and supervision are specified as follows: the interdisciplinary team will make decisions regarding when the bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the bed rail.

Resident R8 is a [AGE] year-old resident who was admitted to the facility on [DATE REDACTED]. Resident R8's diagnoses include muscle wasting and atrophy, epilepsy, dysphagia, abnormalities in gait and mobility, dementia, adult failure to thrive, and peripheral vascular disease.

Resident R8's Admission Minimum Data Set (MDS) completed on 12/1/24 documents that Resident R8 is dependent with rolling left to right, chair and bed transfers, and shower/tub transfers. Resident R8's MDS documents no bed rail in use. Resident R8 was documented as having a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident R8 is cognitively intact.

Resident R8's care plan, dated 11/27/24, documents:

A physical functioning deficit related to mobility impairment and self-care impairment (date initiated 11/29/24).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 525549 Department of Health & Human Services Printed: 09/11/2025 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 525549 B. Wing 01/08/2025

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

Heritage Square Health Care Center 5404 W Loomis Rd Greendale, WI 53129

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

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

F 0700 Interventions include:

Level of Harm - Minimal harm or (Resident R8) requires a Hoyer lift with assistance of two for transfers (date initiated 11/29/24). potential for actual harm (Resident R8) requires total assistance for bed mobility (date initiated 11/29/24). Residents Affected - Few Surveyor reviewed Resident R8's medical record which documents on 12/22/24, Resident R8 had his left arm stuck in his bed rail and staff were unable to remove his arm from the bed rail. Facility staff contacted the provider who gave orders for the facility to contact Emergency Medical Services (EMS).

Surveyor reviewed Resident R8's medical record which documents a bedrail/mattress safety assessment completed

on 12/23/24 indicating Resident R8 was determined safe to have for assist bed rails. Surveyor noted this was after the fall on 12/22/24.

On 1/6/25, at 10:42 am, Resident R8 was observed in bed unattended with assist bed rails observed on both sides of

the bed.

On 1/7/25, 8:32 am, Resident R8 was observed in bed unattended with assist bed rails observed on both sides of the bed.

On 1/7/25, at 9:16 am, Surveyor interviewed Resident R8 who states he had his left arm stuck in his bed rail recently. Resident R8 denies pain or injury after his left arm got stuck. Resident R8 denies any further incidents with his bed rails and states he hangs on to them when staff are providing cares.

On 1/7/25, at 10:01 am, Surveyor interviewed Assistant Director of Nursing (ADON)- C who states therapy works with residents within the facility to determine resident's needs for bed rails. ADON- C states therapy completes the bedrail assessment and notifies nursing staff if bedrail's are determined to be safe.

On 1/7/25, at 10:07 am, Surveyor interviewed Director of Therapy (DOT)- G who states therapy does an initial assessment with the resident to determine bed rail needs. DOT- G indicates therapy starts the assessment and nursing completes and signs off on the assessment if the resident passed the bed rail assessment. Therapy then notifies maintenance to place the bed rails. Surveyor asked DOT- G if a bed rail assessment should be completed prior to bed rails being applied to the resident's bed and DOT- G stated yes, an assessment is required prior to any bed rails being placed on a resident's bed.

On 1/7/25, at 12:59 am, DOT- G notified Surveyor, therapy was notified that Resident R8 had moved from bed A to bed B in his room and the bed rails were already on bed B. Nursing staff then notified therapy of bed rails being on Resident R8's bed on 12/23/24 and requested a bed rail assessment to be completed by therapy.

On 1/8/25, at 9:15 am, Surveyor observed Resident R8 during wound care. Surveyor asked Resident R8 if he was able to grab his bed rails to roll himself side to side, Resident R8 said not by himself. Resident R8 required assistance by staff to grab on to

the bed rail to roll himself on his side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 525549 Department of Health & Human Services Printed: 09/11/2025 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 525549 B. Wing 01/08/2025

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

Heritage Square Health Care Center 5404 W Loomis Rd Greendale, WI 53129

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

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

F 0700 On 1/7/25, at 1:40 pm, Surveyor interviewed Certified Nursing Assistant (CNA)- J who indicates she is familiar with Resident R8 and works with him often. CNA- J states Resident R8 is unable to roll himself side to side Level of Harm - Minimal harm or independently. CNA- J indicates staff will roll Resident R8 to his side and Resident R8 will then hang on to the bed rail during potential for actual harm cares.

Residents Affected - Few On 1/7/25, at 3:03 pm, Surveyor notified Nursing Home Administrator (NHA)- A, Director of Nursing (DON)- B, and ADON- C with concerns of Resident R8 having bed rails on his bed prior to an assessment being completed. NHA- A, DON- B, and ADON- C acknowledged and provided no additional information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 525549