River's Bend Health Services

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on staff and resident interview and record review, the facility did not report an allegation of abuse to

the State Agency (SA) for 1 resident (R) (Resident R1) of 1 sampled resident.Resident R1 reported an allegation of staff-to-resident abuse. The facility did not report the allegation of abuse to the SA.Findings:The facility's Abuse, Neglect, and Exploitation policy, revised 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .Reporting/Response: The facility will have written procedures that include: 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: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result

in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .On 11/24/25, Surveyor reviewed Resident R1's medical record. Resident R1 had diagnosis including lymphedema, type 2 diabetes, chronic pain, ongoing psychiatric follow-up for diagnosis of depression, anxiety, prolonged grief disorder, borderline personality disorder, and multiple personality disorder. Resident R1 had a recent hospitalization for surgery with an exacerbation of psychiatric symptoms post-operatively. Resident R1's Minimum Data Set (MDS) assessment, dated 9/12/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident R1 had intact cognition. Resident R1 was Resident R1's own decision maker. On 11/24/25 at 9:26 AM, Surveyor interviewed Resident R1 who indicated Scheduler (SCH)-C and Driver (DRV)-D accompanied Resident R1 to a physician appointment and argued amongst each other during the transport, including yelling at each other and using vulgar profanities. Resident R1 indicated SCH-C and DRV-D also yelled at Resident R1 in a threatening manner not to tell anyone about the argument which made Resident R1 uncomfortable. Resident R1 reported the incident to staff. Resident R1 did not believe the facility investigated the incident because no one followed-up with Resident R1. On 11/24/25, Surveyor reviewed the facility's grievance file which did not contain a grievance related to Resident R1's allegation of abuse. On 11/24/25 at 12:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed former SCH-C and former DRV-D assisted Resident R1 with transportation to medical appointments. DON-B indicated an argument occurred between SCH-C and DRV-D during a transport and was reported to former Nursing Home Administrator (NHA)-E. DON-B indicated NHA-E would have reported the incident to the SA. DON-B did not have any further information regarding the report.On 11/24/25 at 1:45 PM, Surveyor requested information from NHA-A regarding an argument between SCH-C and DRV-D during a medical transport for Resident R1. On 11/24/25 at 2:37 PM, NHA-A approached Surveyor and indicated the allegation of abuse reported by Resident R1 was not reported to the SA but should have been reported

in accordance with the facility's policy and state and federal regulations.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

River's Bend Health Services

960 S Rapids Rd Manitowoc, WI 54220

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

Based on staff and resident interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (Resident R1) of 1 sampled resident. Resident R1 reported an allegation of staff-to-resident abuse. The facility did not thoroughly investigate the allegation of abuse.Findings include:The facility's Abuse, Neglect, and Exploitation policy, dated 7/15/22, indicates: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .V. Investigation of Alleged Abuse, Neglect, and Exploitation: A. An immediate investigation is warranted when an allegation or suspicion of abuse, neglect, or exploitation or reports of abuse, neglect, or exploitation occur. B. Written procedures for investigations include: Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation .identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s), focusing the investigation on determining if abuse, neglect, exploitation, or mistreatment has occurred, the extent and cause, and providing complete and thorough documentation of the investigation .On 11/24/25, Surveyor reviewed Resident R1's medical record. Resident R1 had diagnoses including lymphedema, type 2 diabetes, chronic pain, ongoing psychiatric follow-up for diagnosis of depression, anxiety, prolonged grief disorder, borderline personality disorder, and multiple personality disorder. Resident R1 had a recent hospitalization for surgery with an exacerbation of psychiatric symptoms post-operatively. Resident R1's Minimum Data Set (MDS) assessment, dated 9/12/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated Resident R1 had intact cognition. Resident R1 was Resident R1's own decision maker. On 11/24/25 at 9:26 AM, Surveyor interviewed Resident R1 who indicated Scheduler (SCH)-C and Driver (DRV)-D accompanied Resident R1 to a physician appointment and argued amongst each other during the transport, including yelling at each other and using vulgar profanities. Resident R1 also indicated SCH-C and DRV-D yelled at Resident R1 in a threatening manner not to tell anyone about the argument which made Resident R1 feel uncomfortable. Resident R1 reported the incident to staff but did not think the facility investigated the incident because no one followed-up with Resident R1. On 11/24/25, Surveyor reviewed the facility's grievance file which did not contain a grievance for Resident R1's allegation of abuse. On 11/24/25 at 12:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed former SCH-C and former DRV-D assisted Resident R1 with transportation to medical appointments. DON-B confirmed an argument occurred between SCH-C and DRV-D during a transport. DON-B indicated the incident was reported to former Nursing Home Administrator (NHA)-E who would have investigated the incident. DON-B did not have any further information regarding the investigation.On 11/24/25 at 1:45 PM, Surveyor requested the facility's investigation for Resident R1's allegation of abuse.On 11/24/25 at 2:37 PM, NHA-A approached Surveyor and indicated the facility did not have an investigation for Resident R1's allegation of abuse. NHA-A indicated an investigation should have been initiated after Resident R1 reported that Resident R1 was yelled at by SCH-C and DRV-D and felt uncomfortable due to vulgar language that was used. NHA-A also indicated SCH-C and DRV-D should have been suspended pending results of the investigation. NHA-A indicated NHA-A interviewed staff that day (11/24/25) after becoming aware of Resident R1's allegation of abuse and discovering arguments between SCH-C and DRV-D occurred on multiple occasions.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet