Bedrock Hcs At Riverdale Llc

F-F609

29360

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 Example 2

Level of Harm - Minimal harm or On 6/27/24 at 10:00 AM, Resident R7 informed staff he had been Raped by two black women. potential for actual harm *On 7/10/24 at 4:30 PM, Surveyor asked NHA A (Nursing Home Administrator) for the full investigation of Residents Affected - Few Resident R7's allegation of being raped by two black women. NHA A stated she had consulted with Corporate Staff and was informed that the allegation did not need to be fully investigated and should be put into a soft file.

NHA A stated Resident R7's allegation should have been fully investigated.

38882

Example 3

Resident R2 admitted to the facility on [DATE REDACTED]. He has diagnoses, including Type 2 Diabetes Mellitus, Chronic Kidney stage 4, metabolic encephalopathy, congestive heart failure, and on 7/3/24 he was diagnosed with a fracture of shaft of humerus left arm.

Resident R2's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/18/24 indicates Resident R2's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 7 out of 15.

Facility policy, entitled Abuse, Neglect, Exploitation, undated, includes: . Protection of resident: the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation . responding immediately to protect the alleged victim and integrity of the investigation . room or staffing changes if necessary to protect the residents from the alleged perpetrator . protection from retaliation .

Facility policy, entitled Compliance with reporting allegations of abuse/neglect/exploitation, dated 10/1/2022, includes protection: the facility will protect residents from harm during an investigation .

Resident R2's Grievance/Concern Form, dated 6/29/24, includes Resident complained that CNAs (Certified Nursing Assistant) were rough during the night, during cares.

Written statements were collected including:

6/29/24 Patient interviewed regarding concern. When initial questioning regarding said concern commenced, patient stated, Well it was like 5:00 AM. I was plopped back and forth. They were rougher than they should have been. When interviewer asked who the two were in this concern, patient could not give a detailed description and only described one of the plurals . calling the one person, Like a big Amazon. When asked what was hurting, patient stated and pointed to left shoulder, adding, My arm is hurting like a b**ch. When interviewer asked a more detailed timeline of events, patient stated, I don't know. It's been hurting all night. Then added, It wasn't nice. It wasn't fun.

6/29/24 Resident R2 was reporting that the night shift girls were being rough with him last night. He said the girls just picked him up and threw him in bed and rolled him. He is in a lot of pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 6/29/24 Went into resident's room to answer his call light. I (CNA M) helped the resident sit up. Resident R2 told me, almost immediately, that last night he was pulled around every which way in bed and was upset about it as Level of Harm - Minimal harm or he has left shoulder pain . and he repeated the same complaint to CNA O when she came into resident's potential for actual harm room.

Residents Affected - Few 7/3/24 On Sunday June 30th I (Minimum Data Set Nurse R) came into finish some admission paperwork. When I was getting ready to leave CNA O came to talk to me about Resident R2's arm. She stated that CNA N was rough with Resident R2 and said she threw him on the bed, and she then said he can barely move his arm. I then told her I would go down and talk to him . Went down to talk to Resident R2. He stated that one of the girls was a little rough with him. I asked him what he meant by a little rough. He stated the tall girl threw him on the bed. I went to the dining room and then started telling the Manager on Duty about what I heard . and before I told her what happened she looked at me and said yes, we know about the pain, and I told her okay thinking she knew that it was already reported to her. Then I called NHA A (Nursing Home Administrator) when I was walking out to go home at 12:43 PM to ask her if she heard about Resident R2 and she stated yes. I know he has an x ray scheduled for Monday July 1, 2024.

Facility staffing schedule, dated 6/29/24, indicates CNA N worked on Resident R2's hallway from 2 PM to 10 PM and as a float CNA from 10PM to 6:30 AM. The schedule also indicates CNA P worked on a different hallway from 2 PM to 10 PM and on Resident R2's hallway from 10 PM to 6:30 AM.

Facility staffing schedule, dated 6/30/24, indicates CNA N worked on a different hallway from 2 PM to 10 PM and on Resident R2's hallway from 10 PM to 6:30 AM. The schedule indicates CNA P worked on Resident R2's hallway from 2 PM to 10 PM and as a float CNA from 10 PM to 6:30 AM.

(It is important to note Resident R2 voiced allegations of CNA N and CNA P being rough with him while providing cares and the facility did not ensure residents were protected during the investigation as CNA N and CNA P were allowed to work without added supervision.

On 7/9/24 at 4:00 PM DON B (Director of Nursing) indicated Resident R2 reported staff were rough with him during the night on 6/28/24-6/29/24. DON B indicated during interviews Resident R2 stated staff plopped him back and forth, were rougher than they should have been, it wasn't nice, and his shoulder hurts like a b**ch. DON B indicated these are allegations of abuse. DON B stated CNA N was allowed to work after the incident was reported, thus not protecting Resident R2 and other residents from further incidents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30992

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety and prevent accidents for 2 of 4 residents (Resident R1, Resident R8) reviewed for resident-to-resident incidents out of a total sample of 13.

At the time Resident R1 and Resident R8 were roommates, Resident R1 struck Resident R8 on the head, unprovoked. Resident R1 is able to propel his wheelchair while Resident R8 is in a Broda chair and unable to lift his arms. CNA C (Certified Nursing Assistant) stated to Surveyor she observed Resident R1 attempt to hit Resident R8 prior to the resident-to-resident altercation that took place on 7/8/24. CNA C stated, during the initial altercation she moved Resident R1 away from Resident R8 and she was struck by Resident R1. The facility failed to provide supervision to prevent resident-to-resident incidents from occurring.

Evidenced by:

The facility's policy and procedure, Abuse/Neglect/Exploitation, undated, documents in part, the following: 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.

Definitions:

Abuse: means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, causes physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical condition, cause physical harm, pain, or mental anguish

Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Physical Abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking

Employee Training: Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; Identifying what constitutes abuse .; Recognizing signs of abuse ., Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: Aggressive and/or catastrophic reactions of residents; Resistance to care; Outbursts or yelling out; Difficulty in adjusting to new routines or staff.

Prevention of abuse: .The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 Resident R1 admitted to the facility 4/11/24 with diagnoses including, but not limited to, the following: Parkinson's Disease with dyskinesia with fluctuations, parkinsonism resting tremor, anxiety, visual hallucinations, Level of Harm - Minimal harm or paranoid behavior, and adult failure to thrive. Resident R1 was hospitalized in May with additional diagnoses of potential for actual harm restlessness and agitation, anxiety disorder and delusional disorder.

Residents Affected - Few On 4/12/24 at 8:05 PM, Resident R1's Physician documented, in part, the following Physician Note: Medical History: Anxiety .paranoid behavior, parkinsonism resting tremor, tobacco abuse and visual hallucinations. Resident R1's Physician documented: Collaborated with the Psychiatry services on Behavioral issues.

Resident R1's Minimum Data Set (MDS), dated [DATE REDACTED], indicated Resident R1's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 6 out of 15. Resident R1 is protectively placed at the facility and has a corporate guardian.

Resident R1's Visual/Bedside Kardex Report indicates Resident R1 requires 1 assist with bed mobility, eating, hygiene, locomotion on and off the unit, toileting, and transferring. Resident R1 requires 2 assist with dressing.

Resident R1's comprehensive care plan indicates the following: (Date Initiated: 4/11/24) Focus: I get nervous and anxious in new situations. In new surroundings related to my anxiety I also have episodes of sadness, anger related to my depression, and I have behavior and verbal episodes related to my psychosis that comes with my Parkinson's. (Date Initiated 4/11/24, Revision on: 6/20/24) Goal: I will attempt to have fewer outbursts of yelling/calling out each day, decreased episodes of anger, sadness, and hallucinations/delusions each day. Interventions: Give me medications, treatments and labs as ordered, If I'm upset, please re-direct the conversation or ask, offer things that are soothing to me.

(Date Initiated 4/14/24) Focus: I sometimes have behaviors which include Hitting during care, Kicking, Shouting, yelling during care, I may say sexually explicit comments/actions (Date Initiated: 4/14/24, Revision on: 6/20/24) Goal: I will calm down with staff intervention. Interventions: Attempt interventions before my behaviors begin; Give me my medications as my doctor has ordered; Help me to avoid situation or people that are upsetting to me; Let my physician known if my behaviors are interfering with my daily living; Make sure I am not in pain or uncomfortable; Please tell me what you are going to do before you begin; Redirection in calm voice if resident is being acting inappropriate; Speak to me unhurriedly and in a calm voice. Note, all interventions are dated 4/14/24.

Resident R1's Progress Notes document, in part, the following behaviors:

On 4/23/24 at 6:51 AM, Resident R1's Progress Notes, document, in part, the following: Resident has been complaints with med on the hours for this shift did because verbally abusive at 4:00 AM with staff member on duty threatening her that he would fight her .

On 4/30/24 at 8:01 AM, Resident R1's Progress Notes document, in part, the following: Resident R1 was awake 3/4 of this night shift, acting out, screaming, unplugging the bed outlets, scraping/clawing staff members

On 5/1/24 at 10:12 AM, Resident R1's Progress Notes document, in part, the following: Resident hitting staff, biting, spitting water, apple juice, going into other resident's rooms. NP (Nurse Practitioner) gave orders to transfer to ER (emergency room )

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 5/1/24 at 3:31 PM, Resident R1's Progress Notes document the following: Writer was called down the 200 hall and was called into residents room as he was uncontrollably swinging/flaring {sic} his arms and legs. Resident R1 was Level of Harm - Minimal harm or seen by several staff members (CNA's, LPN NP) (Certified Nursing Assistants, Licensed Practical Nurse, potential for actual harm and Nurse Practitioner) and others striking out, swinging, punching, flaring, scraping uncontrollably his arms, legs at staff/residents and spitting uncontrollably. Residents Affected - Few

On 5/2/24 at 8:12 AM, Resident R1's a physician note documents, in part, the following: .Documentation and staff behaviorally difficult and dangerous. Patient to himself and others.

On 5/9/24 at 10:32 AM, Resident R1's Progress Notes document, in part, the following: .now resident has started to become inappropriate attempting to touch staff members and trying to take his pants down in the hallway. Resident spitting at staff and disrupting other residents.

On 5/9/24 at 10:53 AM, Resident R1's Progress Notes document, in part, the following: Resident suddenly became increasingly agitated, multiple staff remembers attempted to redirect resident to no avail. Resident inappropriately touching staff members, taking pants down in hall, touching items on the nurses cart. Unable to redirect. Attempting to touch other residents making them agitated. Standing up in the hall, yelling.

The facility submitted a self-report to the State Agency for a resident-to-resident incident between Resident R1 and Resident R8. The investigation is not yet complete.

Summary of Incident: Abuse: Hitting, slapping, threats of harm, assault, humiliation

Affected Person: Resident R8

Accused Person: Resident R1

Date and Time occurred: 7/8/24 at 10:40 AM

Brief Summary of Incident: Resident R1 struck Resident R8 on the top of the head.

DON B (Director of Nursing) documented the following interview with Resident R8.

DON B asked Resident R8, what happened? Resident R8 stated, Resident R1 was trying to get over on his (Resident R8's) side (of the room). Resident R8 told Resident R1 that is my stuff and my side. Resident R1 then told Resident R8 turn it down referring to his television. Resident R1 then hit Resident R8 on top of the head. Resident R8 stated, it really didn't hurt. When questioned by this writer Resident R8 was asked by this writer was his (Resident R1) fist (closed hand) or open handed when he hit you. Resident R8 stated, I don't know. it was the top of my head, and he was behind me. This writer had neuro checks initiated. No redness bruising or elevated area noted on top of head at this time.

Call placed to POA (Power of Attorney) to update

POA (Guardian) for Resident R1 updated on incident.

7/8/24 12:23 PM police contacted updated about resident to resident.

7/8/24 Resident R8's POA updated that room change occurred and Resident R8 has a new roommate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 DON B (Director of Nursing) documented the following interview with Resident R1.

Level of Harm - Minimal harm or What happened; why did you hit Resident R8. Resident R1 stated, He swung at me first and spit at me. DON B stated, That is potential for actual harm not possible as Resident R8 can't move arms and you were behind him.

Residents Affected - Few DON B asked Resident R1, did you hit Resident R8 with your fist or open hand? Resident R8 showed this writer his open hand. Resident R1 expressed that Resident R8's T.V. was loud.

On 7/9/24 Surveyor attempted to speak with Resident R1. Resident R1 declined to speak with Surveyor.

On 7/10/24 at 8:46 AM, Surveyor spoke with Resident R1. Resident R1 discussed unrelated concerns with Surveyor and then ended the conversation before the incident between Resident R1 and Resident R8 could be discussed.

On 7/10/24 at 8:55 AM, Surveyor spoke with CNA D. Surveyor asked CNA D, does Resident R1 have any behaviors. CNA D stated, yes, Resident R1 is aggressive at times he hits and strikes out. Surveyor asked CNA D, does Resident R1 target residents or staff. CNA D stated, Resident R1 is aggressive toward everybody (clarified residents and staff) and has no preference. CNA D stated, Resident R1 has hit her multiple times in the past. Surveyor observed a bruise on CNA D's right forehead. CNA D stated the bruise is from Resident R1 hitting her. CNA D stated, When Resident R1 is trying to hit another resident and I separate the residents I end up getting hit. CNA D stated, Resident R8 cannot physically pick up his hand to hit anybody. Surveyor asked CNA D, when Resident R1 hit Resident R8 on the head on 7/8/24 was this the first time. CNA D stated, No and Resident R1 tried to hit Resident R8 before. CNA D stated, Resident R1 and Resident R8 are roommates CNA D stated, prior to 7/8/24 she observed Resident R1 attempt to hit Resident R8. CNA D intervened and got hit herself. Surveyor asked CNA D, what is the facility doing to keep residents safe. CNA D stated, Resident R1's Sinemet (Parkinson's disease medication) has been adjusted, Resident R1 is now taking Seroquel, was moved to a private room, we provide 1:1 when Resident R1 is agitated and that usually calms him down. Surveyor asked CNA D, are there any other residents afraid of Resident R1. CNA D stated, No.

On 7/10/24 at 9:40 AM, Surveyor spoke with Resident R8. Surveyor asked Resident R8, do you have any concerns with other residents at the facility. Resident R8 stated, yes, Resident R1. Resident R8 stated a couple days ago his roommate, Resident R1, didn't like the volume of the T.V. so he decided to Pound me on the top of my head. Surveyor asked Resident R8 how that made him feel. Resident R8 stated, More scared and it hurt. Resident R8 stated, the facility moved Resident R1 to a different room. Resident R8 stated,

he felt unsafe being in the room with Resident R1. Surveyor asked Resident R8, do you feel safe now that Resident R1 is no longer your roommate. Resident R8 stated, Yes. Resident R8 stated, I was scared of what he was going to do. and I heard he can really hit hard.

On 7/10/24 at 4:39 PM, Surveyor spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A, does Resident R1 have behaviors. NHA A stated yes, acting out, shouting out, and when incidents occur, she puts out

a call to APS (Adult Protective Services) and Resident R1's Guardian, as Resident R1 is protectively placed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 NHA A stated, I feel Resident R1 is not properly placed because of his behaviors. NHA A stated staff have been educated on how to approach Resident R1. NHA A stated, they (clarified corporate) make us take heavy referrals and Level of Harm - Minimal harm or we don't have the staff. NHA A added, They (corporate) just want the beds at 50. NHA A stated, staff are potential for actual harm burnt out she tells them she appreciates them every day. NHA A stated, How do we get normalcy when we get this (behaviors) all over the place. Surveyor asked NHA A, has Resident R1 hit or attempted to hit another Residents Affected - Few resident. NHA A stated, Yes. NHA A added, we had to do a room change and immediate interviews (when Resident R1 hit Resident R8). NHA A stated, Resident R1 is private pay, and he was moved to a private room following the incident between Resident R1 and Resident R8. NHA A stated, We can't provide the care he needs. NHA A stated, with regards to his Parkinson's disease and dementia. NHA A stated, she is not allowed to give him a 30-day notice. Surveyor asked NHA A, who did Resident R1 hit. NHA A stated, Resident R1 hit Resident R8 on top of the head. NHA A stated, DON B (Director of Nursing) interviewed and Resident R8 stated he didn't get hurt. NHA A stated, the facility moved Resident R1 to a different room

in less than 1 hour and they were moved away from each other. NHA A stated, Resident R1 is combative with staff and hits them. NHA A stated, Resident R1 will make inappropriate comments to her such as, I like your body. NHA A stated, Resident R1 touched her inappropriately. Surveyor asked NHA A, where did Resident R1 touch you. NHA A stated, the crotch area (perineal area/private). Surveyor asked NHA A, when did Resident R1 touch your inappropriately. NHA A stated, In May. NHA A stated, there was another occasion when Resident R1 entered her office and asked to Smell her rose. NHA A stated, she thought he meant her plug in (air freshener) and then realized he was referring to her private area and not the plug in. NHA A stated, she made the team aware. Surveyor asked NHA A if

these incidents are documented. NHA A stated, I don't think there's any (documentation). NHA A added, communication does lack in this building. Surveyor asked NHA A, what steps is the facility taking to protect other residents. NHA A stated, Resident R1 has been moved to a private room, medication adjustments, reporting, stopping things when they happen (note, this is reactive Vs proactive.) NHA A added, It's hard to report (to

the State Agency) when I'm told not to. NHA A added, I need to ask (corporate) about every single thing I do

in this building. Surveyor shared Resident R8's interview with NHA A. NHA A stated, she will follow up with Resident R8.

On 7/10/24 at 5:19 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, does Resident R1 have behaviors. DON B stated, Yes. Surveyor asked DON B, what are Resident R1's behaviors. DON B stated, Punching, kicking, spitting water, running down the hall he's very agile, rolled up a washable pad (similar to a Chux) and started swinging at us. DON B added, Resident R1 has thrown a whole glass of water on me. DON B stated, Resident R1's abuse is almost always on (directed at) caregivers. DON B stated, after Resident R1 hit Resident R8, Resident R9 put on his call to notify staff. Surveyor asked DON B, was Resident R1 exhibiting these behaviors at the time he was admitted . DON B stated, yes, he has been having behaviors since he got here and is being seen by Psychiatric services. DON B stated, Resident R1 has never made contact with another resident other than 7/8/24. (Note, per CNA D's interview Resident R1 has attempted contact with Resident R8 prior to the 7/8/24 incident.) Surveyor asked DON B, what is

the facility doing to protect Resident R8 and the other residents. DON B stated, Resident R1 has had his medication adjusted, receiving Psychiatric services, has been sent to hospital on more than 2 occasions. DON B added, when Resident R1 is agitated we change his surroundings, do 1:1. DON B added, that person (doing 1:1) Needs to be willing to be stomped. Surveyor asked DON B, what do you mean by stomped. DON B stated, Hit, struck and He's going to be abusive towards us. Surveyor asked DON B, has Resident R1 attempted to his Resident R8 previously. DON B stated, Not that I'm aware of at all. Surveyor shared CNA D's observation described above. DON B stated, I don't recall that at all.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0837 Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing Level of Harm - Minimal harm or the facility. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33166 Residents Affected - Many Based on record review and staff and vendor interview, the Bedrock corporation governing body did not ensure adequate funds were made available to provide for the safe and efficient management of the facility.

The failure to maintain current payment status with service providers and vendors has the potential to affect all 45 residents in the facility.

The Bedrock corporate governing body failed to maintain current payment status with several service providers and vendors that resulted in delays in getting equipment being fixed, vendors holding facility property after service work and declining to provide additional service work due to (d/t) outstanding bills, vendors refusing to provide further service until payment is received, and the facility aquarium/fish and aviary birds were removed d/t non-payment. The governing body has not paid State bed tax or federal Civil Money Penalties (CMPs), the facility staff have been forced to utilize personal funds as the facility credit card was declined to supplement a resident Christmas party, and the facility pharmacy provider was abruptly terminated after a past due notice was issued including potential of disruption of service. The facility is predominately staffed with agency staff requiring the facility to use vendor contracts which are past due. The failure of the Bedrock governing body to maintain current contract payments has resulted in loss of service and notice of disruption of service. Bedrock corporation's failure to provide sufficient funding to maintain service/vendor contracts has resulted in decreased options for services to the facility and has the potential to negatively impact resident quality of care and quality of life.

Findings as follows:

On [DATE REDACTED] at 11:15 AM, Surveyor spoke to BOM E (Business Office Manager) regarding the facility's accounts payable. BOM E stated the facility utilizes a contracted accounts payable (AP) company. When the facility receives an invoice, she or NHA A (Nursing Home Administrator) signs off on the invoice indicating

the service was provided and billing is accurate and scans the bill to the AP company. BOM E stated it is then the AP company's responsibility to ensure bills are paid on time. When surveyor asked BOM E if she had heard any concerns regarding the facility's financial state, BOM E stated it is well-known the facility is in litigation for several non-payment issues, items in the building are not being fixed, staff have paid out of pocket for items and have not been reimbursed, that the facility's van was held by a local vendor and would not be released until they received payment, and the van needs repairs again and the vendor will not fix it as

they are still owed money.

On [DATE REDACTED], Surveyor received an aging vendor report which was eight pages long with multiple vendors listed. The aging vendor report, dated [DATE REDACTED], indicated financing being owed from 30 days to greater than 151 days and totaling in the millions of dollars.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0837 On [DATE REDACTED], the facility received a letter from Alixa Rx pharmacy. The letter states in part, Re: Notice of Past Due Balance. Alixa is providing the facility with notice of past due balance of $200,400.32 including interest Level of Harm - Minimal harm or accrued from delinquent balances. No payment on pharmacy balances has been paid since [DATE REDACTED]. potential for actual harm Pursuant to Section 7.2.1 of the agreement, pharmacy, at its option with three days written notice to facility has the right to declare all invoices immediately due and payable in full; require facility to pay on a cash in Residents Affected - Many advance basis for all facility-pay product, services and house stock until all invoices are current according to payment terms. Pharmacy also has the right to terminate this agreement and charge interest pursuant to the terms of the agreement.

As referenced above, pharmacy is providing 3-day notice that all outstanding invoices are immediately due and payable in full. We request that facility pay the past due balance immediately. Failure to do so will force pharmacy to exercise contractual rights and pursue legal action to recover the outstanding money that is owed. Please provide prompt response to avoid disruption of services provided by pharmacy.

An account statement dated [DATE REDACTED] from Alixa Rx states in part, your account is past due. Please remit $200, 400.32 to bring your account current. Current balance ,d+[DATE REDACTED] days - $10,269.08, ,d+[DATE REDACTED] days $16, 535.00, ,d+[DATE REDACTED] days $11,055.33, over 120 days $172,809.99, total outstanding balance $224,844.52.

On [DATE REDACTED] at 3:45 PM, Surveyor spoke to a Confidential Employee regarding the pharmacy. The confidential employee stated about 30 days ago, the facility abruptly stopped using Alixa pharmacy and started with a different pharmacy. The Confidential Employee stated, I assume it was due to outstanding funds owed to Alixa pharmacy.

Surveyor reviewed the vendor aging report for Sysco (a food service provider). According to the aging report dated [DATE REDACTED], Sysco is owed $31,407.12. The aging vendor report shows the facility owes out greater than 151 days.

On [DATE REDACTED] at 12:30 PM, Surveyor spoke to CSR G (Customer Service Representative) from Sysco. CSR G indicated the facility has 25 outstanding invoices currently totaling $25,382.85. Surveyor asked CSR G if Sysco is continuing to provide service to the facility. CSR G stated Sysco is continuing service currently and working with the company.

On [DATE REDACTED] at 4:30 PM Surveyor interviewed DOC S (Director of Credit) regarding the facility's line of credit at Sysco. DOC S stated the corporation owes $600,000 for past due invoices from [DATE REDACTED] and [DATE REDACTED] for the Wisconsin buildings, the corporation is paying $66,000 a month to get back in good standing. DOC S stated

the corporation is delinquent in two out of state buildings and was in talks with the corporation on a resolution for these facility's. DOC S stated the representative from the corporation is no longer responding to calls from Sysco, DOC S stated Sysco will make one final attempt on [DATE REDACTED], to reach the corporation if they do not talk with someone from the corporation or agree upon a resolution for the delinquent accounts Sysco will be forced to stop shipments to all of Bedrock corporation including the Wisconsin facility's.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0837 On [DATE REDACTED] at 12:45 PM, Surveyor interviewed APR H (Accounts Payable Representative) from Synapse Health, the facility's Durable Medical Equipment (DME) provider. Surveyor asked APR H what type of DME is Level of Harm - Minimal harm or provided to the facility. APH R stated oxygen concentrators, CPAP (Continuous Positive Airway Pressure) potential for actual harm supplies, respiratory supplies, mattresses, and Broda chairs. APR H stated the facility owes the company $15,111.49 plus June billing which will be roughly an additional $3.000.00. APR H stated the facility was told Residents Affected - Many the company would stop providing service on [DATE REDACTED]; however, we are giving the facility more time to make

a payment - if no payment is received, we will stop providing service.

Surveyor reviewed the vendor aging report for [NAME], Chevrolet Car Dealer, and auto repair shop. According to the aging report dated [DATE REDACTED], [NAME] is owed $1,279.76. The aging vendor report states, they claim we owe more waiting for an email from them with the correct amounts owed, the vendor report shows

the facility owes out greater than 151 days.

On [DATE REDACTED] at 10:10 AM, Surveyor interviewed APR I (Accounts Payable Representative) from [NAME] Chevrolet. Surveyor asked APR I what service they provide for the facility. APR I stated [NAME] Chevrolet provides auto repair work on the facility van. Surveyor asked APR I if the facility owes the company money, APR I stated the facility has several outstanding bills dating back as far as 2022. Surveyor asked APR I if the company is continuing to provide work for the facility. APR I stated not at this time - unless the facility pays up front, we are not performing service. Surveyor asked APR I what the facility owes the company? APR I stated $2,218.05 which is greater than 120 days old.

On [DATE REDACTED], Surveyor spoke to BOM E at 11:15 AM. BOM E confirmed the facility van is in need of current service and cannot be repaired at [NAME] Chevrolet unless paid up front d/t (due to) outstanding bills. Surveyor asked BOM E if the facility utilizes the van to transport residents, BOM E stated yes. BOM E stated, I know they have to pull over at times to rev the engine to keep it going.

On [DATE REDACTED] at 3:45 PM, Surveyor spoke with Confidential Employee regarding facility finances. Confidential Employee stated the company that provided the fish and birds removed them due to non-payment and residents miss the fish and birds.

Surveyor reviewed the vendor aging report for Serenity Aquarium. According to the aging report dated [DATE REDACTED], Serenity is owed $4,083.54. The aging vendor report shows the facility owes out greater than 151 days.

The facility utilizes an electronic health record company Point Click Care (PCC). According to the aging report dated [DATE REDACTED], PCC is owed $13,152.83 with bills greater than 150 days out. The facility's accounts payable firm provided an invoice dated [DATE REDACTED]; the terms of the invoice state net 30, meaning the bill is due

in 30 calendar days after being billed, due date [DATE REDACTED]. The accounts payable provided a check payable to PCC dated [DATE REDACTED] in the amount of $1,937.10 - this check was for invoice dated [DATE REDACTED]; additionally, a second check was provided in the amount of $3,874.20 dated [DATE REDACTED] for invoices from [DATE REDACTED] and [DATE REDACTED].

On [DATE REDACTED] at 11:45 AM, Surveyor spoke with AR L (Accounts Receivable) at Point Click Care. A representative was to return Surveyor's call. This call has not been returned.

On [DATE REDACTED] at 8:15 AM, Surveyor received a call from AR L. AR L stated the company owes $276,700.70 in outstanding service. The company last paid a bill in March for services rendered in November and December of 2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0837 On [DATE REDACTED] at 9:51 AM Surveyor received an email from PCC stating a payment was received on [DATE REDACTED] for $1,937.10. A demand letter has expired, and next step is to issue a termination letter. Non-payment is putting Level of Harm - Minimal harm or the account, as a whole, at risk for service disruption. potential for actual harm

On [DATE REDACTED] at 4:45 PM, Surveyor spoke with DM F (Dietary Manager). DM F stated the facility was not able Residents Affected - Many to get the stove hood in the kitchen cleaned timely d/t concerns regarding payment. DM F stated they did finally come and complete it. DM F stated the robot coupe needed parts the facility was unable to get the parts as the facility credit card was declined. DM F stated she had to purchase a blender using her personal funds so she could blend resident foods. DM F stated another dietary staff member purchased a blender as well with personal funds. DM F stated neither she nor the dietary staff were reimbursed for their purchases. DM F stated they would not have been able to puree foods for residents needing a pureed diet if they did not purchase the blenders.

On [DATE REDACTED] at 11:15 AM, Surveyor asked BOM E regarding the use of agency staff. BOM E confirmed the facility is predominately staffed with agency employees. BOM E stated the facility is in litigation d/t non-payment with a staffing agency.

Surveyor reviewed the vendor aging report for Primetime Staffing, a staffing agency. According to the aging report dated [DATE REDACTED], Primetime staffing is owed $672,085.06. The aging vendor report states, attorney is handling. The vendor report shows the facility owes out greater than 151 days.

On [DATE REDACTED] at 11:20 AM, Surveyor attempted to contact Primetime Staffing; Surveyor left a message with no return call.

Surveyor reviewed the vendor aging report for Twin Med, a medical supply company. According to the aging report dated [DATE REDACTED], Twin Med is owed $27,045.14. The aging vendor report shows the facility owes out greater than 151 days.

The facility's AP provided a check dated [DATE REDACTED] showing Twin Med was paid $7,182.09.

On [DATE REDACTED] at 9:45 AM, Surveyor placed a call to Twin Med and is waiting a return call.

Surveyor made several attempts to contact this Vendor on ,d+[DATE REDACTED], ,d+[DATE REDACTED], and ,d+[DATE REDACTED] with no return call.

Surveyor reviewed the vendor aging report for Southwest Community Action Program (SWCAP), which provides LIFT transportation arrangements for facility residents. According to the aging report dated [DATE REDACTED], SWCAP is owed $14,463.54. The aging vendor report shows the facility owes out greater than 151 days.

On [DATE REDACTED] at 5:00 PM, Surveyor asked SD J (Senior Director) what service SWCAP provides the facility. SD J stated SWCAP provides transportation van services through the LIFT company. Surveyor asked SD J if the facility owes SWCAP outstanding bills. SD J stated there is outstanding bill of roughly $14,000 owed. SD J stated SWCAP has spoken with the facility and stated the facility needs to pay their outstanding invoices; the company is no longer providing rides that are billed directly to the nursing home or residents that do not have

a payment source due to outstanding bills owed by the company.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0837 Surveyor reviewed the vendor aging report for Comprehensive Therapy Specialist, a pharmacy consulting agency. According to the aging report dated [DATE REDACTED], Comprehensive Therapy Specialist is owed $9,778.50. Level of Harm - Minimal harm or The aging vendor report shows the facility owes out greater than 151 days. potential for actual harm

An invoice provided to Surveyor dated [DATE REDACTED] states in part, due to the delinquent payment status for this Residents Affected - Many facility, medical record reviews were performed through [DATE REDACTED], and no fall reviews were performed. Payment is due no later than 15 days after invoice date. Payments more than 30 days past due are subject to a 10% late fee. We appreciate your prompt payment.

On [DATE REDACTED] at 12:55 PM, Surveyor left a message with Comprehensive Therapy Specialist.

On [DATE REDACTED] at 4:30 PM, Pharmacist Q returned the call to Surveyor. Pharmacist Q stated the facility does have an outstanding bill; however, the company called them today and is scheduling payment for all outstanding costs.

Surveyor reviewed the vendor aging report for Centers of Medicare and Medicaid Services (CMS). According to the aging report, the facility owes CMS $83,888.88 for CMPs. According to CMS, they last sent a notice to

the facility on [DATE REDACTED] with a total amount due of $180,056.04 with a due date of [DATE REDACTED] with an amount offset of $38,704.38 which was sent on [DATE REDACTED].

According to Wisconsin Division of Medicaid Service (DMS), the facility has a monthly bed tax assessment of $9,860.00 with a total owed of $427,784.

The corporation utilizes MetLife dental and vision benefits. The facility's accounts payable shows the corporation owes $102,147.27 as of [DATE REDACTED]. The corporation paid $34,222.40 toward this balance on [DATE REDACTED].

On [DATE REDACTED] at 4:45 PM, when Surveyor spoke with DM F and asked if she had the facility's vision and dental insurance, DM F stated she did and recently used the service without concern.

On [DATE REDACTED] at 4:15 PM, Surveyor spoke to NHA A (Nursing Home Administrator) regarding the facility's financial situation. Surveyor asked NHA A if she was aware of financial issues, delinquent bills, or companies discontinuing services to the facility due to non-payment concerns. NHA A stated there are some concerns with bills not being paid and some companies, such as [NAME] Chevrolet, are refusing to provide service d/t delinquency. NHA A stated the company credit card has been declined and staff have used their own funds to provide a Christmas party for the residents or to buy equipment needed in the kitchen. NHA A stated she currently is owed $140.00 for mileage from several months ago. NHA A stated there is some concerns companies may not want to continue to provide service d/t non-payment.

On [DATE REDACTED] at 4:40 PM, Surveyor asked the Confidential Employee if any residents or residents have been impacted regarding money issues. The Confidential Employee indicated at this point the Confidential Employee is not aware of a negative outcome however the potential is there. The facility is making abrupt changes in providers which appears to be related to payment concerns. It is well-known the company owed Alixa Rx a large sum of money. The van needs repairs and is used to transport residents and there is a risk

this may breakdown completely. The company credit card is declined frequently, and equipment is not getting repaired timely forcing staff to buy equipment out of their own pocket.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0837 On [DATE REDACTED] at 1:10 PM, Surveyor received a call from FO K (Facility Owner), FO K stated he is paying his bills, and he would never do anything to harm the residents. FO K stated many of the companies Surveyor is Level of Harm - Minimal harm or looking at the facility has stopped using their service as they were not providing the services or charging potential for actual harm ridiculous amounts of money. FO K stated I know the issues with Sysco were a big deal and I am working on that. FO K also stated Twin Med account was automatically delinquent; now he pays on order. Surveyor Residents Affected - Many asked FO K what the company is doing to pay their bills, FO K stated he is working with AP and getting the company bills paid.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 525321

F-F610

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0609 29360

Level of Harm - Minimal harm or Example 2 potential for actual harm

On 6/27/24 10:00 AM, Resident R7 informed staff he had been Raped by two black women. Residents Affected - Some

On 7/10/24 at 4:30 PM, Surveyor asked NHA A (Nursing Home Administrator) if Law Enforcement was contacted when Resident R7 had made the allegation of being raped by two black women. NHA A stated no, Law Enforcement had not been contacted. Surveyor asked NHA A if the allegation had been reported to the State Agency. NHA A stated no, the allegation had not been reported to the State Agency. NHA A stated she had consulted with Corporate Staff and was informed that Law Enforcement did not need to be called and the allegation did not need to be reported to the State Agency. NHA A was to put the information in a soft file.

NHA A stated that Law Enforcement should have been contacted when Resident R7 made the allegation and the allegation should have been reported to the State Agency.

38725

Example 3

Resident R3 and Resident R4 had a verbal altercation that turned into a physical altercation on 5/4/24. All appropriate actions were taken at the time of the incident.

The facility's 5-day self-report was not submitted to the State Agency timely. It was submitted on 5/30/24.

On 7/10/24 at 4:27 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A should the 5-day self-report be submitted timely, NHA A stated yes, it should be. Surveyor asked NHA A the resident-to-resident incident with Resident R3 and Resident R4 occurred on 5/4/24 at 11:30 PM, the 5-day completed self-report was submitted on 5/30/24, is that timely; NHA A said no it is not, it was not submitted timely, that is correct.

Surveyor received additional information 7/11/24 from NHA A. NHA A provided emails that she had submitted the 5-day completed self-report to OCQ (Office of Caregiver Quality) on 5/15/24. OCQ responded to NHA A on 5/16/24 instructing her that the 5-day completed self-report must be submitted via the MIR (Misconduct Incident Reporting) system. Per emails between NHA A and her Regional Corporate Consultant, NHA A didn't have access to the MIR system initially. Given this additional information, incident occurred on Saturday 5/4/24. The 5-day completed self-report was due on 5/10/24.

Despite additional information, the 5-day completed self-report was still not submitted timely.

38882

Example 4

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0609 Resident R2 admitted to the facility on [DATE REDACTED]. He has diagnoses, including Type 2 Diabetes Mellitus, Chronic Kidney stage 4, metabolic encephalopathy, congestive heart failure, and on 7/3/24 he was diagnosed with a fracture Level of Harm - Minimal harm or of shaft of humerus left arm. potential for actual harm Resident R2's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/18/24 indicates Residents Affected - Some Resident R2's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 7 out of 15.

Facility policy, entitled Abuse, Neglect, Exploitation, undated, includes: . reporting of all alleged violations to

the administrator, state agency, adult Protective Services, and to all other required agencies within specified time frames: immediately but not later than two hours after the allegation is made, if the events that caused allegation involve abuse or result in serious bodily injury . not later than 24 hours if the events that caused

the allegation do not involve abuse and do not result in serious bodily injury .

Facility policy, entitled Compliance with reporting allegations of abuse/neglect/exploitation, dated 10/1/2022, includes: the facility will protect residents from harm during an investigation . the facility will report all alleged violations and all substantiated incidences to the state agency and to all other agencies as required . notify

the appropriate agencies immediately as soon as possible but no later than 24 hours after discovery of the incident . in the case of serious bodily injury no later than two hours after discovery or forming the suspicion .

Resident R2's Grievance/Concern Form, dated 6/29/24, includes Resident complained that CNAs (Certified Nursing Assistant) were rough during the night, during cares.

Written statements were collected including:

6/29/24 Patient interviewed regarding concern. When initial questioning regarding said concern commenced, patient stated, Well it was like 5:00 AM. I was plopped back and forth. They were rougher than they should have been. When interviewer asked who the two were in this concern, patient could not give a detailed description and only described one of the plurals . calling the one person, Like a big Amazon. When asked what was hurting, patient stated and pointed to left shoulder, adding, My arm is hurting like a b***h. When interviewer asked a more detailed timeline of events, patient stated, I don't know. It's been hurting all night. Then added, It wasn't nice. It wasn't fun.

6/29/24 We, CNA N (Certified Nursing Assistant) and CNA P, went in doing our usual rounds with Resident R2 . on 6/28/24 at 10 PM last night shift we did our usual rounds with Resident R2, and he has been complaining of his shoulder since he was admitted , and he be confused no matter what time of the night it may be . We just did our usual change for all our residents. Since he admitted no matter how we may twist or turn or guide him, even right out of his chair he is in pain. CNA P and I both changed Resident R2 together and he was soiled first round and he complained and the next rounds he had large bowel movements. We had to do a bed change for him because he soils really bad. Other than us having to turn him multiple times and Resident R2 being confused . that was all the encounter we had far as Resident R2 night shift. {sic}

6/29/24 CNA N and I (CNA P) went in during all three rounds together to change him. He complained about his left arm while being changed a couple of times. I let him know that he was being changed because he can't be left in bowel movement, but he still continued to ask why.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0609 6/29/24 Resident R2 was reporting that the night shift girls were being rough with him last night. He said the girls just picked him up and threw him in bed and rolled him. He is in a lot of pain. Level of Harm - Minimal harm or potential for actual harm 6/29/24 Went into resident's room to answer his call light. I (CNA M) helped the resident sit up. Resident R2 told me, almost immediately, that last night he was pulled around every which way in bed and was upset about it as Residents Affected - Some he has left shoulder pain . and he repeated the same complaint to CNA O when she came into resident's room.

7/3/24 On Sunday June 30th I (MDS Nurse R) came into finish some admission paperwork. When I was getting ready to leave CNA O came to talk to me about Resident R2's arm. She stated that CNA N was rough with Resident R2 and said she threw him on the bed, and she then said he can barely move his arm. I then told her I would go down and talk to him . Went down to talk to Resident R2. He stated that one of the girls was a little rough with him. I asked him what he meant by a little rough. He stated the tall girl threw him on the bed. I went to the dining room and then started telling the Manager on Duty about what I heard . and before I told her what happened

she looked at me and said yes, we know about the pain, and I told her okay thinking she knew that it was already reported to her. Then I called NHA A (Nursing Home Administrator) when I was walking out to go home at 12:43 PM to ask her if she heard about Resident R2 and she stated yes. I know he has an x ray scheduled for Monday July 1, 2024.

Investigation Report, dated 7/3/24, includes date of incident 7/3/24 . Facility was notified via hospital that resident had a left humerus fracture facility-initiated investigation. Timeline of events: 7/3/24 the facility notified that resident had a humerus fracture and investigation initiated. 7/3/24 employee statements were reviewed. 7/3/24 skin assessments on residents with BIMS (Brief Interview for Mental Status) of 12 or less completed. 7/3/24 resident interviews completed . Summary of critical information: Grievance was regarding CNA N being rough during cares on 6/29/24. CNA N suspended 7/3/24 . Conclusion: resident was admitted to the facility 6/12/24 post hospitalization from a fall from his truck. Resident had reported left arm pain since admission to facility. On 6/28/24 the nurse practitioner ordered an X-ray of resident's left arm for complaints of chronic pain. X-ray was not obtained as resident was transferred to the hospital for hypoglycemia. Upon return to the facility an interview was completed with the resident. He stated that he felt safe at the facility. When interviewed about CNA N being rough with cares resident reported although she was rough with cares

it did not worsen his arm pain. A pain assessment was completed upon return and resident did not report any discomfort. Resident has as needed Tylenol available. No new concerns identified during investigation per residence and staff interviews. Primary care physician reviewed X-ray results and stated that the fracture was most likely spontaneous and pathological as there was no major injury. This is suggestive there may be

a possibility of underlying cancer. Although resident reports that staff were rough with cares, indicating poor customer service, I am unable to substantiate abuse at this time based on the investigation completed .

On 7/9/24 at 10:25 AM during an interview, CNA M indicated when a resident voices concern such as staff being rough, or staff threw me on the bed are allegations of abuse and should be reported immediately.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 0609 On 7/9/24 at 4:00 PM DON B (Director of Nursing) indicated Resident R2 reported staff were rough with him during the night on 6/28/24-6/29/24. DON B indicated during interviews Resident R2 stated staff plopped him back and forth, Level of Harm - Minimal harm or were rougher than they should have been, it wasn't nice, and his shoulder hurts like a b**ch. DON B potential for actual harm indicated these are allegations of abuse and should be reported immediately to the state agency within 2 hours or within 24 hours. DON B indicated she was responsible for reporting to the state agency, and she did Residents Affected - Some not do it until x ray results showed a fracture on 7/3/24. DON B indicated she should have filed an initial allegation report on 6/29/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30992 potential for actual harm Based on interview and record review, the facility did not ensure that in response to allegations of abuse, Residents Affected - Few neglect, exploitation, or mistreatment all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse for 3 of 5 residents (Resident R13, Resident R7, and Resident R2) reviewed for abuse.

The current NHA A (Nursing Home Administrator) verbally reported two (2) allegations of abuse towards Resident R13 to the previous NHA. The previous NHA did not document the allegations, investigate the incidents, and educate all staff to prevent future reoccurrence.

Resident R7 told staff he had been raped by two black women on 6/27/24. The allegation was not fully investigated.

Resident R2 told staff that two staff members on the night shift were rough with him and now he has pain in his right shoulder. The alleged staff members were not suspended pending investigation and remained working with Resident R2 without additional supervision.

Evidenced by:

The facility's policy, Abuse/Neglect/Exploitation, undated, states, in part, as follows: Policy: It is the policy of

this facility to provide protections for the health, welfare and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse, neglect, exploitation

Identification of Abuse, Neglect and Exploitation: .Psychological abuse of a resident observed; Verbal abuse of a resident overheard.

Investigation of Alleged Abuse, Neglect and Exploitation: An immediate investigation is warranted when suspicion of a crime, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. Investigating different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and providing complete and thorough documentation of the investigation.

Reporting/Response: Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences. Defining how care provision will be changed and/or improved to protect residents receiving services; Training of staff on changes made a demonstration of staff competency after training is implemented .

Example 1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 23 525321 Department of Health & Human Services Printed: 09/18/2025 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 525321 B. Wing 07/10/2024

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

Riverdale Health Care Center 1000 N Wisconsin Ave Muscoda, WI 53573

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 Resident R13 was admitted to the facility on [DATE REDACTED] with diagnoses including, but not limited to, dementia and cerebral vascular accident (stroke). Level of Harm - Minimal harm or potential for actual harm Resident R13's Admission MDS (Minimum Data Set) dated 5/10/24 indicates Resident R13 has a BIMS (Brief Interview of Mental Status) of a 7 out of 15, which indicates he is severely cognitively impaired. Resident R13 has a APOAHC Residents Affected - Few (Activated Power of Attorney for Health Care).

CNA D (Certified Nursing Assistant) was employed as an agency staff member from 2/3/24 - 5/30/24. On 5/30/24 the facility notified the agency to make CNA D a DNR (Do Not Return) to the facility. There is no documentation regarding the reason.

The facility's current NHA A (Nursing Home Administrator) previously worked as the SW (Social Worker) from 2/26/24 - 5/1/24 prior to becoming the current NHA A.

NHA A verbally reported two (2) allegations of abuse to the previous NHA. There is no documentation that

the previous NHA documented or investigated the allegations. The previous NHA A did not document the allegations, investigate the incidents nor educate all staff to prevent reoccurrence.

On 7/10/24 at 11:00 AM and 3:16 PM, Surveyor spoke with NHA A. Surveyor asked NHA A if she had any concerns regarding CNA D (Certified Nursing Assistant) during his employment. NHA A stated, Yes. NHA A stated, when she was working as the Social Worker, she observed CNA D egging on Resident R13. Note, Egging on is defined as follows: Incite, urge ahead, provoke and To urge or encourage (someone) to do something that is usually foolish or dangerous. Note NHA A added, CNA D would set off Resident R13 and NHA A observed CNA D having fun upsetting Resident R13. NHA A stated, Resident R13 gets upset easily and CNA D would say things such as, Are you mad again? NHA A stated, Resident R13's family reported the same concern to her (while she was the Social Worker) which she verbally reported to the previous NHA. Surveyor asked NHA A, would you consider this abuse. NHA A stated, I would. NHA A added, It falls under the definition of humiliation. NHA A observed Resident R13 being abused by CNA D and Resident R13's family observed and verbally reported the same concern to NHA A while

she was the acting Social Worker. The previous NHA did not document the allegations, investigate the incidents, and educate all staff to prevent future reoccurrence. Surveyor asked NHA A, should the previous NHA have documented these allegations of abuse. NHA A stated, Yes. Surveyor asked NHA A, should the previous NHA have investigated these allegations of abuse NHA A stated, Yes. Surveyor asked NHA A, should the previous NHA have educated all staff following these observed allegations of abuse. NHA A stated, yes.

On 7/10/24 at 4:00 PM, Surveyor spoke with Resident R13. Surveyor asked Resident R13, how do staff treat you. Resident R13 stated,

The real bad ones (staff/agency staff) are gone. Resident R13 stated, CNA D (Certified Nursing Assistant) didn't treat me bad at first, but then it got bad. and He threw me in bed and treated me bad. Resident R13 added, CNA D would call me names. It is important to note, Resident R13 is severely cognitively impaired and has difficulty remembering events that were observed by the current NHA A and reported by family to NHA A.

The previous NHA did not document the allegations, investigate the incidents, and educate all staff to prevent future reoccurrence.

Cross Reference: