Crossroads Care Center Of Mayville

F-F609) or the facility must clearly document the rationale for not reporting.

It should be noted using the reasonable person concept a person would not be expected to be called names or swore at in their own home and may experience fear from such encounter.

Surveyor requested Resident R5 and Resident R6's electronic health records documenting this incident including any assessments, nurses' progress notes, updated care plan, etc. Surveyor was not provided any electronic health records documenting the investigation of this incident.

Of note there was no evidence the facility documented an immediate assessment and a lack of willful intent. Assessed Resident R5 and Resident R6's-care plan- intervened or implemented interventions to prevent reoccurrence and keep other residents safe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 9 525616 Department of Health & Human Services Printed: 09/08/2025 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 02/21/2025

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50285

Residents Affected - Few Based on interview and record review the facility did not develop a comprehensive, person-centered care plan for 1 of 6 sampled residents (Resident R3) reviewed for person-centered care plans.

Resident R3 does not have a comprehensive care plan that includes triggers and monitoring targetd behaviors.

Evidenced by:

Facility policy entitled Comprehensive Care Plans, dated 1/25, states, in part; It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and Compliance Guidelines: 1.

The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care.3. The comprehensive care plan will describe, at a minimum, the following: . f. Resident specific interventions that reflect the resident's needs and preferences . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (minimum data set) assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.8. Qualified staff responsible for carrying out interventions specified in the car plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Example 1

Resident R3 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Dementia in other diseases classified elsewhere, unspecified severity, with psychotic disturbance, Anxiety disorder, unspecified, Major Depressive disorder, recurrent, unspecified, and Need for Assistance with personal care.

R3s most recent Minimum Data Set (MDS) dated [DATE REDACTED] states that Resident R3 has a Brief Interview of Mental Status (BIMS) of 12 out of 15, indicating that Resident R3 has mild cognitive impairment.

Resident R3's Comprehensive Care Plan states, in part:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 525616 Department of Health & Human Services Printed: 09/08/2025 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 02/21/2025

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 0656 Focus: The resident demonstrates a pattern of situational and/or coping problems in areas such as: being alone after her spouse leaves. Psychosocial well-being, Mood state and/or behavioral symptoms. Date Level of Harm - Minimal harm or initiated 10/21/22. Revision on 7/1/24. Goal: The residents mental health and psychosocial well-being will be potential for actual harm enhanced: staff encouragement, reminders of how well she is doing. Date initiated 10/21/22. Revision on 9/19/24. Interventions: Encourage the resident to express her thoughts and feelings. Date initiated 10/21/22. Residents Affected - Few Help the resident feel welcome, accepted, acknowledge and well-received. Provide structure and guidance to help the resident feel safe, competent, involved, secure, valued, and appreciated. Work to help the resident develop a role that provides him/her with a sense of purpose and builds esteem/worth. Date initiated 10/21/22.

Focus: The resident has an active order for anti-anxiety medication due to Anxiety disorder. Date Initiated 8/19/22. Revision on 8/19/22. Goal: The resident will be free from discomfort or adverse reaction to anti-anxiety therapy through the review date. Date initiated: 8/19/22. Revision on 9/19/24. Interventions: Administer anti-anxiety medications as ordered by physician. Date initiated 8/19/22. Monitor/document/report PRN (as needed) any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated 8/19/22. Provide re-assurance if resident becomes anxious. Allow her to express herself, offer to call her husband. Date initiated 12/10/24 .

Focus: The resident has an active order for antidepressant medication for Depression. Date initiated 9/17/24. Revision on 9/17/24. Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date: 9/17/24 isolation, suicidal thoughts, withdrawal, decline in ADL (Activities of Daily Living) ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes. Date initiated 9/17/24. Provide reassurance if resident expresses sadness. Encourage her to think about things

she enjoys like her visits with her husband and looking at animals outside her window. Date initiated 12/10/24.

Resident R3's Progress Notes, state in part:

On 10/1/24 at 2:02 PM, Type: Behavior Note: During shower resident called CNA (Certified Nursing Assistant) a bitch several times and hit CNA in her right arm x2. CNA able to complete shower, no further issues.

On 11/24/24 at 8:32 AM, Type: Behavior Note: Resident continues to refuse medications in the morning in an aggressive way. She never just states that she does not want it. She yells, sometimes swears, sometimes demands staff to get out. This is not just on the NOC (nocturnal, overnight) shift but have heard that this is happening on staff on the PM shift as well and she is not getting her important meds. Writer has noticed that

she has been getting some of the Parkinson's effects of the tremors while drinking and just lying in bed. When I have brought this to her attention, she always states to me BULLS*** several times. She is also being non-compliant with wanting to be turned for her coccyx/sacrum wound while lying in bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 525616 Department of Health & Human Services Printed: 09/08/2025 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 02/21/2025

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 0656 On 12/3/24 at 11:01 AM, Type: Behavior Note: Resident refuses shower after three attempts by three different people. Resident started to raise her voice and become extremely agitated after final attempt. Level of Harm - Minimal harm or potential for actual harm On 12/21/25 at 1:37 AM, Type: Behavior Note: Resident has been acting out at night. She has been pushing

the call light continuous at times stating that she is sinking. All CNA and RN (Registered Nurse) has checked Residents Affected - Few the bed and the alarm on the bed is not going off. Today CNA went into check/change her and she slapped her. She has been getting more and more physical with the staff regarding cares.

On 2/21/25 at 5:45 AM, Type: Behavior Note: Resident again, with the nurse helping to provide cares tried to kick the CNA a couple of times while changing her. The CNA asked her not to do that and the resident responded I can if I want to. The RN corrected her and stated NO, you can not. You should not be hitting anyone.

On 2/21/22 at 2:22 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) and asked her about Resident R3's behaviors. CNA G stated she has heard of Resident R3 being aggressive with other staff members but never with her. CNA G stated that Resident R3 can become resistive with cares and refuse medications at times. Surveyor asked CNA G what interventions were in place for Resident R3's behaviors. CNA G stated that she will reapproach, not push her, and back off. Surveyor asked CNA G where Resident R3's behaviors and interventions would be listed. CNA G stated they would be in the care plan and CNA Kardex.

On 2/21/24 at 2:27 PM, Surveyor interviewed RN D (Registered Nurse) and asked her about Resident R3's behaviors. RN D stated that Resident R3 refuses cares and yells a lot, and that she does attempt to hit and kick with cares. Surveyor asked RN D what interventions were in place for Resident R3's behaviors. RN D indicated that she attempts redirection or distraction, or will step away and let a new face reapproach. RN D indicated that when Resident R3 is agitated, they do cares in pairs, meaning that two staff will go into Resident R3's room together to provide cares. RN D stated that Resident R3 becomes triggered when her husband is not here, that he comes twice a day but when he leaves Resident R3 gets more agitated. Surveyor asked RN D where these behaviors, triggers, and interventions would be listed. RN D stated they would be in Resident R3's care plan.

On 2/21/25 at 2:11 PM, Surveyor interviewed CNA H and asked her about Resident R3's behaviors. CNA H stated that Resident R3 will refused cares a lot and get confused. CNA H stated that Resident R3 doesn't like to be touched or messed with too much. CNA H stated that Resident R3 will say no and become real aggressive. CNA H stated that Resident R3 can become agitated and did try to kick her during cares. CNA H stated that Resident R3's husband comes every day, but

she becomes more agitated when he leaves. Surveyor asked CNA H what interventions were in place for Resident R3's behaviors. CNA H stated that she offers Resident R3 food, drink, or tries to change the subject to distract her. CNA H states that Resident R3 likes hot chocolate and various snacks, so she will offer her those. Surveyor asked CNA H if these behaviors or interventions were listed on the CNA Kardex. CNA H stated no, behaviors are not on the Kardex. Surveyor asked CNA H if they were written down anywhere for staff to know how to care for Resident R3. CNA H indicated that staff just know what triggers Resident R3 and what can calm her down.

On 2/21/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing) and asked her if a resident's behaviors would be listed on the CNA Kardex. DON B stated no, behaviors are not on the Kardex. Surveyor asked DON B if a resident's behaviors should be listed on their care plan. DON B stated yes, behaviors should be listed on the care plan, and also that staff would get information related to resident behaviors in shift-to-shift report.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 525616 Department of Health & Human Services Printed: 09/08/2025 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 02/21/2025

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 0656 The facility failed to develop and implement a care plan that described the specific aggressive behaviors that Resident R3 was displaying, nor did they outline triggers or interventions to enable staff to provide quality care to Resident R3. Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 525616 Department of Health & Human Services Printed: 09/08/2025 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 02/21/2025

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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49436

Residents Affected - Few Based on interview and record review, the facility did not provide behavioral health services to ensure a resident received the highest practicable mental and psychosocial well-being. The facility did not create a comprehensive assessment and plan of care to address substance use disorder (SUD) for 1 of 2 residents (Resident R2) reviewed for SUDs.

Resident R2 has a SUD. The facility failed to create a care plan related to Resident R2's alcohol consumption and failed to implement interventions for behaviors associated with Resident R2's alcohol consumption.

This is evidenced by:

The facility policy titled Safety for Resident with Substance Use Disorder, dated 1/25, states in part: It is the policy of this facility to create an environment that is as free of accident hazards as possible, for residents with a history of substance use disorder. Definitions: substance use disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home . 1. Residents with a history of SUD will be assessed for risks . Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors. 2. When substance use is suspected .facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner. 3. Care planning interventions will address risks by providing appropriate diversions for resident and encouraging resident to seek out facility staff to discuss their plan of care .7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with their resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision.

Resident R2 admitted to the facility on [DATE REDACTED] with diagnoses including alcohol abuse, repeated falls, unsteadiness on feet.

Resident R2's Brief Interview for Mental Status (BIMS) on 11/26/24 has a score of 15, indicating Resident R2 is cognitively intact.

Resident R2's Medication administration and Treatment administration records for January 2025 and February 2025 do not include monitoring of behaviors and/or substance use.

Resident R2's physician orders dated 2/21/25 does not include an order stating Resident R2 can consume alcoholic beverages.

Resident R2's comprehensive care plan dated 2/21/25, states in part:

Focus: The resident is functioning at an independent level in his leisure pursuits.

Goal: The resident will make one positive statement about his leisure pursuits to staff weekly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 525616 Department of Health & Human Services Printed: 09/08/2025 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 02/21/2025

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 0740 Interventions: Encourage the resident to pursue appropriate leisure interest on his/her own. Introduce yourself to the resident to establish a friendly and professional rapport. Offer the resident independent leisure Level of Harm - Minimal harm or materials for him to pursue. Provide the resident with a copy of the activity calendar on a monthly basis. potential for actual harm Of note, Resident R2's comprehensive care plan does not include Resident R2's substance use disorder, nor the triggers Residents Affected - Few related to substance use. Resident R2's comprehensive care plan does not include goals related to Resident R2's substance use disorder. Resident R2's comprehensive care plan does not include person-centered interventions to prevent substance use nor mitigate the risks associated with substance use. Resident R2's comprehensive care plan does not include Resident R2's behaviors associated with Resident R2's substance use.

Resident R2's nurses' progress notes state:

12/26/25 8:39 AM Resident appears to be intoxicated, smells of alcohol and slurring words. He was in the dining room arguing with other resident and family .

1/17/25 23:31 (11:31 PM) Nurse was called into the resident room for a fall. When Nurse arrived in room resident was getting up and trying to get into the bed. He had one shoe on and one shoe off with a regular sock on the other foot. This was making his foot slip. The CNA quickly assisted him to prevent a further fall, and the nurse assisted with the other side. Resident sat on the side of the bed and allowed the nurse to do a partial assessment. Resident stated that he did not hit his head. He stated that he was OK and that hisprde [sic] is the only thing that is hurt. Resident's BP (blood pressure) is low due to him being intoxicated all other vital signs are WNL (within normal limits) .

1/19/25 10:59 AM Per administration no resident were to go outside for smoking or store runs due to the freezing temperatures. Message was relayed to resident however resident refused to stay inside stating it's not that cold. Resident made multiple trips outside to smoke and went to Kwik Trip.

The facility provided an investigation summary related to Resident R2. The summary states in part: On 1/26/25 around 12:00 PM, Resident R2 had a resident-to-resident altercation with Resident R1. Resident R2 threatened to kill Resident R1. It was noted that Resident R2 had been drinking that morning. Staff have noted on many different occasions, empty bottles of alcohol laying around Resident R2's room along with a smell of alcohol coming off Resident R2.

On 2/21/25 at 11:19 AM, Surveyor interviewed RN D (Registered Nurse) regarding Resident R2's behaviors. RN D indicated Resident R2 likes to talk like he's tough and will make sexual comments to the staff.

On 2/21/25 at 12:39 PM, Surveyor interviewed SSD E regarding Resident R2's substance use, behaviors and his care plan. SSD E indicated Resident R2's substance use, behaviors and interventions should be on the care plan. SSD E indicated there should be a care plan to monitor and intervene with Resident R2's substance use and associated behaviors and Resident R2 does not have a care plan related to substance use or behaviors.

On 2/21/25 at 1:00 PM, Surveyor interviewed DON B regarding Resident R2. DON B indicated Resident R2 should have a care plan for his substance use and associated behaviors but does not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 525616