Bedrock Hcs At Greendale Llc

F-F686).

Resident R3's Kardex as of 3/18/25 documents: Skin integrity - Encourage staff to reposition me every 2-3 hours. Air mattress setting checks. Heel boots to bilateral heels. Staff will provide heel boots at all times. Toileting - I need total assist x 1 for toileting.

Surveyor noted although Resident R3 is identified to be always incontinent of bowel and bladder and has a stage 3 pressure injury and MASD, Resident R3's Kardex included no indication of how often Resident R3 is to be checked and changed for incontinence.

On 3/17/25 Surveyor spoke with (name of medical group) Nurse Practitioner (NP)-F. NP-F reported Resident R3 has a stage 3 pressure injury on her coccyx, which she was told was present on admission, and several partial thickness areas of MASD to bilateral buttocks. Surveyor asked what she thought was the cause of the MASD. NP-F stated, probably combination of wetness from incontinence and shearing. Surveyor asked if the facility implemented a check and change schedule related to incontinence. NP-F reported she did not know. Surveyor asked if Resident R3's MASD is a result of wetness from incontinence, would she expect routine or more frequent checking and changing for incontinence. NP-F stated. Of course. I'm sure they have a protocol for weight shifting and skin care incontinence protocol. Surveyor asked if she has communicated the need for weight shifting and skin care/incontinence care. NP-F stated. I have, it would be in my notes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 525549 Department of Health & Human Services Printed: 09/04/2025 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 03/19/2025

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 0690 Surveyor confirmed NP-F progress note dated 2/24/25 documents (in part) . HPI: The pressure ulcer is located on the coccyx and has been present for 5 weeks. The pressure ulcer was present on admission. Level of Harm - Minimal harm or According to the NPIAP (National Pressure Injury Advisory Panel) staging system, the pressure ulcer is potential for actual harm classified as stage 3. Additional factors that contribute to non-healing include bed-bound status, bowel incontinence and bladder incontinence. Provider Comments document Prognosis: Guarded, dependent on Residents Affected - Few offloading and moisture management. Discussed pressure relief and redistribution strategies. Patient is on

an appropriate support surface for the patient to use when supine and should be on a weight shifting schedule and skin care/continence schedule per facility protocol. The balance of moisture is critical to wound healing. I have given caregivers instructions about managing skin moisture which include using a skin barrier and wicking agent. Patient wears an adult brief. Consider Foley catheter in future if urine management becomes a problem.

On 3/19/25 at 11:02 AM, Surveyor spoke with MDS-O who reported it was her understanding that nursing is responsible for creating care plan related to problem areas identified.

On 3/18/25 at 9:00 AM, Surveyor met with Acting Director of Nursing (DON)-C to discuss concerns: Resident R3 admitted to the facility with pressure injuries and MASD to her coccyx. Resident R3 was identified to be always incontinent of bowel and bladder and dependent for toileting hygiene. A personalized care plan was not implemented to manage Resident R3's incontinence and potential effect on her skin. Resident R3's coccyx MASD progressed to

a stage 3 pressure injury. Acting DON-C reported she will review information and see if there is any additional information to provide. No additional information was provided prior to survey exit.

On 3/19/25 at 12:30 PM, Nursing Home Administrator (NHA)-A, Acting DON-C, and DON-B were advised of

the above concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 525549

F-F690).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 525549 Department of Health & Human Services Printed: 09/04/2025 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 03/19/2025

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 0686 On 3/18/25 at 9:00 AM, Surveyor met with Acting Director of Nursing (DON)-C to discuss concerns: Resident R3 admitted to the facility with pressure injuries and MASD to her coccyx. Treatment was not implemented until Level of Harm - Actual harm 5 days later, after Resident R3 was seen by the wound physician. At this time a stage 3 pressure injury was identified

on her coccyx which required mechanical debridement of necrotic tissue and slough. Resident R3 was readmitted Residents Affected - Few following hospitalization on [DATE REDACTED]. The facility did not complete a comprehensive assessment and measurements of Resident R3's wounds and no treatments were implemented until 2 days later, which included only barrier cream and not the previously ordered (appropriate) treatment for stage 3 pressure injury. 5 days later,

the wound physician documented Resident R3's coccyx stage 3 pressure injury declined/was larger in size and required mechanical debridement of necrotic tissue and slough. Acting DON-C reported she will review information and see if there is any additional information to provide. No additional information was provided prior to survey exit.

On 3/19/25 at 12:30 PM, Nursing Home Administrator (NHA)-A, Acting DON-C, and DON-B were advised of

the above concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 525549 Department of Health & Human Services Printed: 09/04/2025 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 03/19/2025

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38146

Residents Affected - Few Based on observation, interview and record review the facility did not ensure that residents who are incontinent of bowel and bladder receive appropriate treatment and services to prevent skin-related complications for 1 of 2 (Resident R3) residents reviewed for bowel and bladder.

Resident R3 admitted to the facility with pressure injuries and Moisture Associated Skin Damage (MASD). A care plan was not implemented to manage Resident R3's incontinence.

Findings include:

Resident R3 admitted to the facility on [DATE REDACTED] and has diagnoses that include severe hypoxic ischemic encephalopathy, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with hypoxia, anoxic brain damage, Cerebral Infarction, Heart Failure, Major Depressive Disorder, spondylosis lumbosacral region, Hidradenitis Suppurativa and Epilepsy.

The facility policy titled Continence and Incontinence - Assessment and Management review date 1/2025 documents (in part) .

. Policy Statement

1. The staff and practitioners will appropriately screen for, and manage, individuals with incontinence.

2. Management of incontinence will follow relevant clinical guidelines.

Policy Interpretation and Implementation

1. As part of the initial and ongoing assessments, the nursing staff and physician will screen information related to incontinence.

3. Periodically (as required and when there is a change in voiding), staff will define each individual's level of continence, referring to the criteria in the Minimum Data Set (MDS).

4. As part of its assessment, nursing staff will seek and document details related to continence. Relevant details include the following: Voiding patters (frequency, volume, nighttime or daytime, quality of stream, etcetera).

8. The staff and physician will identify individuals with complications of existing incontinence, or who are at risk for such complications (e.g., skin maceration or breakdown or perineal dermatitis).

18. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence,

the staff will initiate a toileting plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 525549 Department of Health & Human Services Printed: 09/04/2025 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 03/19/2025

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 0690 b. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and Level of Harm - Minimal harm or change strategy. potential for actual harm c. A check and change strategy involves checking the resident's continence status at regular intervals and Residents Affected - Few using incontinence devices or garments. The primary goals are to maintain dignity and comfort level and to protect the skin.

Resident R3's admission bowel and bladder assessment dated [DATE REDACTED] documents: Always incontinent of bowel and bladder. Functional incontinence - cognitive impairment (brain injury). Does not recognize need to void/defecate. Is there a care plan in place? Yes.

Resident R3's Admission MDS dated [DATE REDACTED] documents: Always incontinent of B&B (bowel and bladder) and dependent for toileting hygiene and bed mobility.

The Care Area Assessment (CAA) documented: Is this resident at risk of developing pressure ulcers? Yes. Resident has one or more unhealed pressure ulcer(s) at stage 2 or higher, or one or more likely pressure ulcers that are unstageable at this time as indicated by: Number of stage 3 pressure ulcers = 1. Always incontinent. Moisture Associated Skin Damage = Yes. Describe impact of this problem/need on the resident and your rationale for care plan decision: Check and change. Apply treatment.

Surveyor noted although Resident R3 was identified to be always incontinent of bowel and bladder, admitted to the facility with pressure injuries and MASD to her coccyx (which progressed to a stage 3 pressure injury), Resident R3 did not have a care plan implemented to manage bowel and bladder incontinence (Cross reference