Crossroads Care Center Of Mayville

F-F104's falls to determine the root cause nor implement fall prevention interventions based on the identified root cause to prevent future falls.

Findings include:

The facility's policy and procedure entitled, Accidents/Fall Prevention Program, dated 1/30/2023, was reviewed by Surveyor. The policy documents: The facility strives to promote safety, dignity and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Any episode of a fall should be documented in risk management. Each fall must be investigated and/or assessed using a root cause analysis process to determine the cause of the fall and prevent any further injury. The individual care plan is to be updated with any changes or new interventions post fall and communicated to staff and implemented.

Resident R104 was admitted to the facility on [DATE REDACTED], at 12:50 PM with a diagnosis of TBI (Traumatic Brain Injury) with subarachnoid hemorrhage. Resident R104 has a Guardian for decision making. The Admission Nursing Assessment conducted on 6/29/24, at 12:50 PM, assesses Resident R104 as a fall risk.

Surveyor notes Resident R104 was at the facility from 6/29/24 through 7/3/24 and had 4 falls during this time. Resident R104 discharged prior to the completion of an Admission Minimum Data Set (MDS) assessment.

The initial plan of care for Fall Risk dated 6/29/24, with a resolved date of 7/1/2024, with a goal date of 9/27/2024 documents interventions dated 6/29/24: Call light within reach; Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs; Ensure proper footwear; Follow facility fall protocol.

The initial plan of care for ADL (activity of daily living) self-care performance deficit due to TBI with weakness, and poor impulse control, which increases risk for complications, such as falls and incontinence, dated 6/29/24 with revisions on 7/1/24, 7/5/24 and 7/8/24, and a goal date of 9/27/2024, was reviewed. The interventions documented: 7/1/24 provide adequate adaptive equipment necessary during transfer; toilet riser in bathroom; encourage to use call light; wheelchair with anti-rollbacks; 7/2/24 an intervention of do not leave alone in room. There is a revision date of 7/5/2024 with no changes in interventions. There is a revision date of 7/8/2024 with interventions: bariatric bed with bolsters and extender; call family and allow them to talk as this helps decrease agitation; encourage resident to stay in the common area when awake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 525616 Department of Health & Human Services Printed: 09/13/2025 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 525616 B. Wing 08/15/2024

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

Crossroads Care Center of Mayville 305 S Clark St Mayville, WI 53050

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 The Kardex for staff care printed 8/14/2024, includes under Resident Care: call family and allow them to talk as this helps decrease agitation; encourage resident to stay in the common area when awake. Level of Harm - Minimal harm or potential for actual harm The Kardex does not identify fall risk interventions for safety.

Residents Affected - Few FALLS

* On 6/29/24, at 4:15 PM, Resident R104 had an unwitnessed fall in the hallway. The fall documentation includes, improper footwear and ambulating without assistance. There is not a comprehensive assessment to determine causative factors to identify what Resident R104 was doing at the time of the fall, when they were last assisted by staff and to support the immediate intervention of Resident R104 to be placed in a wheelchair by the nurses station, then after supper, was transferred to a low bed, in their room.

The initial plan of care for fall risk dated 6/29/24, with a resolved date of 7/1/2024, with a goal date of 9/27/2024, documented interventions starting 6/29/24 include to ensure proper footwear.

Surveyor notes the fall was not thoroughly investigated to include causative factors leading up to the fall, along with identification of fall prevention interventions related to possible causative factors.

On 8/15/24, at 9:15 AM, (Nursing Home Administrator) NHA-A provided additional fall investigation information that is not part of the medical record. The supplemental fall investigation information documented Resident R104 was last toileted at 3:00 PM, had socks on and was not using an assistive device when they fell on [DATE REDACTED]. The intervention was to keep in a common area.

* On 7/2/24, at 3:10 PM, Resident R104 had an unwitnessed fall in their room. The fall incident does not include a comprehensive assessment of causative factors leading up to the fall.

The initial plan of care for ADL (activity of daily living) self-care performance deficit due to TBI with weakness and poor impulse control which increases risk for complications such as falls and incontinence, dated 6/29/24 with revisions on 7/1/24, 7/5/24 and 7/8/24, and a goal date of 9/27/2024, was reviewed;

The interventions: 7/1/24, provide adequate adaptive equipment necessary during transfer; toilet riser in bathroom; encourage to use call light; wheelchair with anti-rollbacks.

On 8/15/24, at 9:15 AM, NHA-A provided additional fall information that is not part of the medical record which documented Resident R104 was in an activity prior to the fall. The activity staff took Resident R104 to their room to use

the bathroom. The staff left Resident R104 in their room to get staff to assist with toileting. The staff was re-educated to review Kardex for fall interventions.

Surveyor notes Resident R104's Kardex does not identify Resident R104 as a fall risk or provide instructions to not leave Resident R104 alone in their room. The Kardex does not document fall prevention interventions. The ADL plan of care does documents on 7/3/24: do not leave Resident R104 alone in room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 525616 Department of Health & Human Services Printed: 09/13/2025 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 525616 B. Wing 08/15/2024

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

Crossroads Care Center of Mayville 305 S Clark St Mayville, WI 53050

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 7/3/24, at 12:00 PM, Resident R104 had an unwitnessed fall from bed. The fall incident does not document a comprehensive assessment to determine causative factors, along with interventions to prevent further falls. Level of Harm - Minimal harm or The fall incident report documents Resident R104 was looking for their brother and was put to bed a few minutes prior potential for actual harm to the fall. The immediate intervention implemented was 15 minute checks and transferred back to bed.

Residents Affected - Few Surveyor notes there is no comprehensive assessment to determine causative factors leading up to the fall to determine appropriate interventions to prevent further falls.

On 8/15/24, at 9:15 AM, NHA-A provided additional fall information that is not part of the medical record. There was no information for possible causative factors leading up to the fall. The interventions were 15 minute checks.

Surveyor notes there are no plan of care changes for 7/3/2024 fall and prevention.

* On 7/3/24 at 6:40 AM Resident R104 had a fall with staff present. Resident R104 was urinating on the floor as they were walking to the bathroom. The staff was not able to use a gait belt for assistance, Resident R104 legs become weak and they fell to the floor.

There is not a documented comprehensive assessment to assess for injury, There was no immediate intervention documented related to this fall.

Surveyor notes the fall care plan does not address Resident R104's 4 falls. The initial plan of care for ADL(activity of daily living) self-care performance deficit due to TBI with weakness and poor impulse control which increases risk for complications such as falls and incontinence, dated 6/29/24 with revisions on 7/1/24, 7/5/24 and 7/8/24, and a goal date of 9/27/2024, was reviewed;

The interventions: 7/1/24 provide adequate adaptive equipment necessary during transfer; toilet riser in bathroom; encourage to use call light; wheelchair with anti-rollbacks. On 7/2/24 an intervention of do not leave alone in room was added.

On 8/15/24, at 9:15 AM, NHA-A provided additional fall information that is not part of the medical record. There was not documentation related to a comprehensive assessment of Resident R104 at the time of the fall. There was no documentation of immediate interventions to prevent further injury.

On 7/3/24 at 11:56 AM Resident R104 family requested Resident R104 to be transferred to the hospital. Resident R104 did not return back to the facility.

Surveyor informed Nursing Home Administrator-A Resident R104's falls were not comprehensively assessed to identify a root cause analysis, along with appropriate fall prevention interventions identified and Resident R104's care plan revised.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 525616 Department of Health & Human Services Printed: 09/13/2025 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 525616 B. Wing 08/15/2024

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

Crossroads Care Center of Mayville 305 S Clark St Mayville, WI 53050

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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21855

Residents Affected - Few Based on record review and interview, the facility did not ensure a resident received a prescribed medication as ordered by the physician. This was observed with 1 (Resident R104) of 6 resident medication reviews.

* Resident R104 hospital discharge medication orders were not transcribed correctly upon admission to the facility. Resident R104 did not receive the prescribed medication as directed by the physician.

Findings include:

Resident R104 was admitted to the facility on [DATE REDACTED] from the hospital. Resident R104's hospital discharge summary dated 6/29/2024, documents propranolol10 mg (milligram) at breakfast and lunch. There is not a diagnosis indicated with this medication. The hospital history and physical includes propranolol prescribed for tremors. Resident R104 history and physical paperwork does not include documentation of diagnoses of hypertension.

The facility physician orders, on 6/29/24, documents propranolol 10 mg daily for hypertension.

Surveyor notes the order was transcribed incorrectly and was only ordered daily vs the prescribed 2 times daily.

The June (Medication Administration Record) MAR, indicates propranolol 10 mg one time a day for hypertension. This is documented as being administered on 6/30/24 at 6:30 AM.

The July MAR, indicates propranolol 10 mg daily for hypertension. This is documented as being administered

on 7/1/24 - 7/3/24, at 6:30 AM.

On 8/14/24, at 3:14 PM, Surveyor, requested any information related to Resident R104's propranolol prescription,

during the daily exit meeting with Nursing Home Administrator (NHA)-A, Director of Nurses (DON)-B, Consultant-D and Consultant-E.

On 8/15/24, at 9:15 AM, NHA-A and Consultant-E spoke with Surveyor and provided a Medication Occurrence form. Consultant-E stated the Assistant Director of Nurses (ADON)-C caught the prescription error during a 2nd check of admission orders. They thought it was saved in the computer. Consultant-E stated DON-B inputs the medication orders into the computer first and then there is a 2nd check of the orders and ADON-C thought the propranolol order was saved in the computer.

The Medication Occurrence form, dated 7/3/24, documents, the medication was clarified to be for tremors,

the nurse practitioner was updated, this was discovered after Resident R104 was transferred out of the facility.

Surveyor informed NHA-A and DON-B of the concern Resident R104 did not receive the correct medication order at

the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 525616