Bedrock Hcs At Riverdale Llc

F-F700 of the State Operations Manual prior to installing bed rails/enabler bars.

The facility failed to re-assess Resident R3's risk of entrapment, complete a safety/gap test with the air mattress, provide written documentation of ongoing monitoring of bed rails, and provide documentation of alternatives tried prior to installing bed rails.

The facility failed to re-assess Resident R7's risk of entrapment, complete safety/gap tests with the air mattress, provide written documentation of ongoing monitoring of bed rails, provide documentation of alternatives tried prior to installing bed rails, and provide evidence of the individual risk and benefits that were reviewed.

The facility failed to assess Resident R10's risk of entrapment, complete safety/gap tests with the air mattress, provide written documentation of ongoing monitoring of bed rails, provide documentation of alternatives tried prior to installing bed rails, and provide evidence of the individual risk and benefits that were reviewed.

Evidenced by

The facility policy, Proper Use of Bed Rails, dated 10/1/22, states, in part:

Policy: It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. Definitions: Bed Rails . Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0700 Policy Explanation and Compliance Guidelines: Resident Assessment: 1. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's Level of Harm - Minimal harm or needs, and whether or not the use of bedrails meets those needs: a. Medical diagnosis, conditions, potential for actual harm symptoms, and/or behavioral symptoms b. Size and weight c. Sleep habits d. Medications e. Acute medical or surgical interventions f. Underlying medical conditions g. Existence of delirium h. Ability to toilet self safely Residents Affected - Some i. Cognition j. Communication k. Mobility l. Risk of falling. 2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails .4. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself .Informed Consent: 6. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails .Installation and Maintenance of Bed Rails: 12. The facility will assure the correct installation and maintenance of bed rails, prior to use. This includes: a. Checking with

the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible. Rails should be selected and placed to discourage climbing over rails. b. Ensuring that the bed's dimensions are appropriate for the resident by: i. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed; .iii. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment; iv. Ensuring the bed frame, bed rail and mattress do not leave a gap wide enough to entrap a resident's head or body, regardless of mattress width, length, and/or depth. v. Checking bed rails regularly to make sure they are still installed correctly, and have not shifted or loosened over time .d. Conducting routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair .Ongoing Monitoring and Supervision: .16. Responsibilities of ongoing monitoring and supervision are specified as follows: .b. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of bed/mattress/rail .d. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.

According to the Food and Drug Administration (FDA), The FDA recommends the following actions to prevent deaths and injuries from entrapment and falls from adult portable bed rails: .

When installing and using bed rails:

*Confirm that the age, size, and weight of the person using the bed rails are appropriate for the bed rails used.

*Install bed rails using the manufacturer's instructions to ensure a proper fit.

*Ensure that the safety strap or bed rail retention system is permanently attached to the rail and secured to

the bed frame according to the manufacturer's instructions.

*Regularly inspect the mattress and bed rails for gaps and areas of possible entrapment. *Regardless of mattress width, length, and depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a patient's head or body.

*Use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0700 *Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, Level of Harm - Minimal harm or mattress pad or waterbed. potential for actual harm *Check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. Residents Affected - Some *When in doubt, call the manufacturer of the bed rails for assistance.

https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-consumers-and-caregiv ers-about-adult-portable-bed-rails

Example 1

Resident R3 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Parkinson's Disease with Dyskineasia: Fibromyalgia; Spinal Stenosis; Abnormal Posture; and Age-Related Osteoporosis.

Resident R3's most recent Minimum Data Set (MDS) with a target date of 2/21/25, indicates Resident R3 had a Brief Interview for Mental Status (BIMS) of 03, indicating Resident R3 has a severe cognitive impairment.

Resident R3's Physician orders include, in part: bilateral 1/4 enabler bars: used to assist with repositioning and transfers. Order Date: 5/17/24.

Air Mattress for wound care. Order Date: 4/11/23.

Resident R3's most recent Bed Rail Assessment was completed on 5/17/24.

Resident R3 was assessed on 2/3/25 to be At Risk for falls.

Resident R3's Comprehensive Care Plan, indicates, in part: .Bed Mobility: Assist of 1, may use 2 assist as needed. Revision on 7/13/21 .Bilateral 1/4 enabler bars: used to assist with repositioning and transfers. Date Initiated: 6/20/24 .Transfer with assist of Hoyer (Full Body Lift) and 2 assist. Revision on: 6/15/23 .At Risk for Falls . Date Initiated: 1/5/17 .Provide Pressure reduction/relieving mattress. Revision on: 4/25/21 .

Of note, Resident R3's Post Fall Evaluation on 8/3/24 indicates, in part: Fall Details: .Date/Time of Fall: 8/3/24 1:31AM .Activity at the time of fall: resident rolled out of bed .

There is no evidence that Resident R3 had the following: measurements completed for a safety/gap test with the air mattress; an updated bed rail assessment for entrapment; written documentation of ongoing monitoring of bed rails or audits of bed rails; and documentation of alternatives tried prior to installing bed rails.

Example 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0700 Resident R7 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Osteoarthritis (a degenerative joint disease where the protective cartilage that cushions the ends of bones wears down over time, leading to Level of Harm - Minimal harm or pain, stiffness, and reduced joint function); muscle wasting, and difficulty in walking. potential for actual harm Resident R7's most recent MDS with a target date of 12/30/24 indicates Resident R7 has a BIMS score of 15, indicating Resident R7 is Residents Affected - Some cognitively intact.

Resident R7's physician orders include, in part: bilateral 1/4 enabler bars: used to assist with repositioning and transfers in/out of bed. Order Date: 5/17/24.

Pressure redistribution mattress (Air Mattress). Order Date: 4/18/22.

Resident R7's most recent Bed Rail Assessment was completed on 5/17/24.

Resident R7 was assessed on 2/5/24 to be At Risk for falls

Resident R7's Comprehensive Care Plan, indicates, in part: .Bed Mobility: Assistance of (one). Revision on: 4/21/22 . Positioning bar to be placed on right side of bed to enable repositioning. Revision on: 5/20/23 .Transfer to Broda Chair with Hoyer .EZ Stand with assist of 2 for sitting balance support. Revision on: 2/16/24 .Provide pressure reduction/relieving mattress low air loss mattress. Revision on: 9/30/22 .At Risk for Falls .Date Initiated: 4/21/22 .

On 4/3/25 at 1:50PM Surveyors interviewed Resident R7 and asked if she recalled receiving any education and/or risk and benefits regarding the use of bedrails. Resident R7 indicated she did not.

There is no evidence Resident R7 had the following: measurements completed for a safety/gap test with the air mattress; an updated bed rail assessment for entrapment; written documentation of ongoing monitoring of bed rails or audits of bed rails; documentation of alternatives tried prior to installing bed rails; and evidence of what individual risks and benefits were reviewed.

Example 3

Resident R10 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: Secondary Malignant Neoplasm (Cancer that has the potential to spread to other parts of the body) of Breast; Secondary Malignant Neoplasm of Bone; Muscle Wasting and Atrophy; and Unsteadiness on Feet.

Resident R10's most recent MDS with a target date of 3/13/25 indicates, Resident R10 has a BIMS of 15, indicating Resident R10 is cognitively intact.

Resident R10's Physician orders include, in part: bilateral enabler bars to assist with bed mobility and transfers in and out of bed. Order Date: 12/9/24.

Of note, no order for an air mattress was noted in the physician orders provided by the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0700 Resident R10's Comprehensive Care Plan, indicates, in part: .Bed Mobility: assistance of (1) assist as needed when feeling fatigued .Revision on: 7/18/24 .1/4 enabler bars to assist with repositioning and transfers in/out bed. Level of Harm - Minimal harm or Date Initiated: 8/9/24 .Transfer assistance of (1) as needed when feeling fatigued. Revision on: 7/18/24 .At potential for actual harm Risk for Falls .Date Initiated: 7/5/24 .Air Mattress .Revision on: 3/31/25.

Residents Affected - Some Of note, no evidence of a bed rail assessment was noted in Resident R10's medical record and no further documentation was provided by the facility when requested.

Resident R10 was assessed on 12/9/24 to be At Risk for falls.

On 4/3/25 at 1:50 PM, Surveyors interviewed Resident R10 and asked if she recalled receiving education and/or risk and benefits for bed rail use. Resident R10 indicated she couldn't recall due to memory issues with her current treatment regimen and requested we contact Family Member R who may have more information.

On 4/3/25 at 2:54 PM, Surveyors contacted Family Member R who indicated that she did not receive education and/or risk and benefits in regard to bed rails.

There is no evidence Resident R10 had the following: measurements completed for a safety/gap test with the air mattress; a bed rail assessment for entrapment; written documentation of ongoing monitoring of bed rails or audits of bed rails; documentation of alternatives tried prior to installing bed rails; and evidence of what individual risks and benefits were reviewed.

50285

Example 4

Resident R6 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part, Multiple Sclerosis, Morbid Obesity, Type 2 Diabetes Mellitus, Muscle wasting and atrophy, Paraplegia, Unspecified lack of coordination, Muscle weakness generalized, Unspecified abnormalities of gait and mobility, anxiety disorder unspecified, Major depressive disorder unspecified and Pain unspecified.

Resident R6's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/19/25 indicates Resident R6 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating, Resident R6 is cognitively intact.

Resident R6's physician orders include, in part: Bilateral 1/4 enabler bars: used to assist in repositioning and transfers in/out of bed. Start Date: 5/17/24.

Resident R6's Comprehensive Care Plan, states, in part; .Bed mobility moderate to max assistance of (2) staff. Start Date: 8/22/16 . Transfer assistance of three with Hoyer. Start Date: 8/22/16 . Bilateral 1/4 side rails on bed to promote independent bed mobility. Start Date: 8/22/16 At risk for falls. Start Date: 2/17/25 . Provide pressure reduction/relieving mattress. Start Date: 8/16/21.

Resident R6's MDS Section GG indicates the following: Mobility: The resident is totally dependent on staff for rolling in bed, sitting to lying and lying to sitting on the side of the bed, and for transferring in/out of bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0700 Resident R6 was assessed on 2/17/25 to be at risk for falls.

Level of Harm - Minimal harm or Resident R6 did not have measurements for gaps with the mattress and bed rails, did not have an updated bed rail potential for actual harm assessment for entrapment, no written proof of risk vs. benefits for bed rails, no ongoing monitoring or audits of bed rails, no alternatives tried prior to installing bed rails, and no written proof of consent for bed rails. Residents Affected - Some

On 4/3/25 at 1:41 PM, Surveyor interviewed Resident R6, who stated he had never signed a consent or been provided education on the risks and benefits of the use of side rails.

Example 5

Resident R5 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part, Cerebral infarction d/t (due to) unspecified occlusion of middle cerebral artery, Type 2 diabetes mellitus, Acute respiratory failure, Morbid obesity, Central auditory processing disorder, Depression unspecified and Metabolic encephalopathy

Resident R5's most recent MDS with ARD of 1/10/25 indicates Resident R5 has a BIMS score of 15 out of 15, indicates that Resident R5 is cognitively intact.

Resident R5's physician orders include, in part: Bilateral 1/4 enabler bars: used for repositioning and transfers in/out of bed. Start Date: 5/17/24.

Resident R5's Comprehensive Care Plan, states, in part; .Bed mobility: assistance of (total assist of 2 staff). Start Date: 7/18/23 . Transfer assistance: assistance of (total assist of 2 staff). Start Date: 7/18/23 . Bilateral 1/4 side rails on bed to promote independent bed mobility. Start Date: 1/30/24 At risk for falls. Start Date: 7/18/23 . Provide pressure reduction/relieving mattress. Start Date: 1/10/24.

Resident R5's MDS Section GG indicates the following: Mobility: The resident needs substantial/maximum assistance of staff for rolling in bed, sitting to lying and lying to sitting on the side of the bed, and dependent on staff for transferring in/out of bed.

Resident R5 was assessed to be a high risk for falls.

Resident R5 did not have measurements for gaps with the mattress and bed rails, did not have an updated bed rail assessment for entrapment, no written proof of risk vs. benefits for bed rails, no ongoing monitoring or audits of bed rails, no alternatives tried prior to installing bed rails, and no written proof of consent for bed rails.

On 4/3/25 at 1:39 PM, Surveyor interviewed Resident R5, who stated he had never signed a consent or been provided education on the risks and benefits of the use of side rails.

Example 6

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0700 Resident R4 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part, Muscle wasting and atrophy, Morbid obesity, chronic kidney disease stage 3, Atrial fibrillation, Chronic pain syndrome, Acute kidney Level of Harm - Minimal harm or failure, other abnormalities of gait and mobility, Encephalopathy unspecified, Difficulty in walking, Weakness, potential for actual harm Depression unspecified and Muscle weakness generalized.

Residents Affected - Some Resident R4's most recent MDS with ARD of 1/10/25 indicates Resident R4 has a BIMS score of 15 out of 15, indicates that Resident R4 is cognitively intact.

R4s's physician orders include, in part: 1/4 enabler bars: use for repositioning and assist with transfers. Start Date: 5/17/24.

Resident R4's Comprehensive Care Plan, states, in part; .Bed mobility: independent. Start Date: 1/10/23 . Transfer assistance: independent with walker or wheelchair. Start Date: 1/13/24 . 1/4 enabler bars: use for repositioning and assist with transfers. Start Date: 6/21/24 At risk for falls. Start Date: 1/10/23 . Provide pressure reduction/relieving mattress. Start Date: 1/10/23 . Air Mattress. Start Date: 4/19/24.

Resident R4's MDS Section GG indicates the following: Mobility: Independent for rolling in bed, sitting to lying and lying to sitting on the side of the bed, and independent on staff for transferring in/out of bed.

Resident R4 was assessed on 1/10/23 to be a high risk for falls.

Resident R4 did not have measurements for gaps with the mattress and bed rails, did not have an updated bed rail assessment for entrapment, no written proof of risk vs. benefits for bed rails, no ongoing monitoring or audits of bed rails, no alternatives tried prior to installing bed rails, and no written proof of consent for bed rails.

On 4/3/25 at 1:34 PM, Surveyor interviewed Resident R4, who stated he had never signed a consent or been provided education on the risks and benefits of the use of side rails.

On 4/3/25 at 2:55 PM, Surveyor interviewed MD M (Maintenance Director) and asked how he assessed the resident for risk of entrapment prior to installing or using bed rails. MD M stated that it would be the nursing department that does that assessment. Surveyor asked MD M if he had done any gap measurements to ensure there would be no entrapments with the air mattresses and bed rails. MD M stated he had never measured the gaps for the mattresses. Surveyor asked MD M how he ensured that the dimensions of the bed were appropriate for the resident's size and weight. MD M indicated that would be therapy or nursing that would do that. Surveyor asked MD M how often was scheduled maintenance or audits completed on the bed rails already in use. MD M stated that he completes a walk around inspection of the facility weekly and tries to check the bed rails at that time to make sure they are working properly. Surveyor asked MD M if he had documentation of bed rail maintenance. MD M indicated that information was all kept in their online maintenance system, and he did not have any logs or documentation of that.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0700 On 4/3/25 at 3:49 PM, Surveyor interviewed DON B (Director of Nursing) and asked how she assessed the resident for risk of entrapment prior to installing or using bed rails. DON B stated that it was maintenance that Level of Harm - Minimal harm or would go around and do measurements. Surveyor asked DON B how often maintenance should be doing potential for actual harm measurements and completing audits on the bed rails. DON B indicated that their policy stated they should be done quarterly. Surveyor asked DON B how often bed rail assessments should be completed on the bed Residents Affected - Some rails already in place. DON B stated those should be done quarterly also, but that they hadn't been completed since last May. Surveyor asked DON B if it was her expectation that they be completed quarterly. DON B stated yes, that would be her expectation. Surveyor asked DON B if the resident or family representative actually signs the bed rail assessment. DON B indicated that residents and/or family members don't physically sign, but when they have the discussion with them, they just type in their name. Surveyor asked DON B if there were any entrapment assessments. DON B indicated no; she did not see an assessment for that. Surveyor asked DON B what kind of education or risk, and benefits was completed with

the residents and or family members for the use of side rails with air mattresses. DON B stated that they were told of the risks and benefits, but that she did not have any documentation of it. DON B pulled up a bed rail assessment on her computer and expanded field 3A, which indicated the following, The positive and negative aspects of side rail/assist bar have been discussed with the resident and/or family, and the resident and/or responsible parties are aware of the risk involved with the side rail use. Surveyor asked DON B if she had any documentation that listed what those risks were. DON B stated that she thought there was something but that she couldn't find it. Surveyor asked DON B if any alternatives are tried before installing

the bed rails. DON B indicated that they use the assessments, such as the bed rail assessment, fall risk assessment, Braden scale, a lift transfer evaluation, fall risk assessment, elopement assessment and ADL (Activities of Daily Living) assessment. Surveyor asked DON B how she would ensure the correct use of an installed bed rail. DON B said that would be the maintenance department. Surveyor asked DON B who would be responsible for measuring the gap between the side rail and the air mattress to reduce the risk of entrapment. DON B said that would be maintenance. Surveyor asked DON B who assesses to determine that the bed dimensions are appropriate for the resident size and weight. DON B said that would be maintenance too. Surveyor asked DON B if the measurements for gaps with the mattress and bed rails, a bed rail assessment that the resident or family signed, and written proof of risk vs. benefits for bed rails should be part of the resident's electronic medical record. DON B stated yes, it should all be included in the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49436 potential for actual harm Based on interview and record review, the facility did not ensure residents are free of any significant Residents Affected - Few medication errors for 1 of 1 residents (Resident R16) reviewed for medications.

Resident R16 was prescribed an antibiotic for right third toe cellulitis. The facility delayed entering the order into Resident R16's Medication Administration Record (MAR) and delayed starting the antibiotic.

This is evidenced by:

The facility's policy titled Non-Controlled Medication Order Documentation dated 10/25/14 states in part; Documentation of Medication Order: Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the physician order or the telephone order or entered int o the electronic medical records system, if it is a verbal order, and

on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) or electronic medical records system. New Handwritten Orders: The nurse on duty at the time the order is received enters

it on the physician order sheet/telephone order sheet or enters the order into the electronic medical records system if not written there by the prescriber. New Verbal Orders: The nurse documents the verbal order and

the reason for its use on the telephone order sheet/physician's order sheet or enters the order into the electronic medical system. Transcribe newly prescribed medications on the MAR or TAR.

Resident R16 admitted to the facility on [DATE REDACTED] with diagnoses including diabetes type 2, closed fracture of the right tibia, fibula, and medial malleolus, (a serious ankle fracture) and dementia.

On 3/6/25, Resident R16 went to the ER (emergency room ). Resident R16's ER report states in part: Resident R16 came in via ambulance from local nursing home with a complaint of right sided .abdominal pain .Right third toe redness and swelling for the last 1 week patient denies any trauma. Currently not on any treatment for the toe. Right third toe redness and swelling with bruising seems early cellulitis to the dorsum (back) of the right foot . Impression: right foot third toe cellulitis. Disposition: Follow-up with podiatrist in 1 week, return if problem worsening or change symptoms, follow-up with primary care doctor in 3 to 5 days for recheck of abdominal pain and right foot. New prescription Keflex (antibiotic) 500 mg capsule 4 times a day for 7 days, quantity 28.

Resident R16's Physician orders include Cephalexin (antibiotic) 500 mg four times a day for infection for 7 days. Order was entered on 3/7/25 with a start date of 3/8/25.

Resident R16's March Medication Administration Record (MAR) indicates Cephalexin (antibiotic) 500 mg by mouth for times a day for infection for 7 days. Order date on 3/7/25 at 9:50 AM. First dose of Resident R16's antibiotic was given

on 3/8/25.

Of note, Resident R16 was seen in theER on [DATE REDACTED] and was prescribed an antibiotic for cellulitis of his right third toe.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0760 On 4/17/25 at 10:19 AM, Surveyor interviewed IDON X (Interim Director of Nursing) regarding medication orders and implementing physician orders. IDON X stated any physician order should be processed within Level of Harm - Minimal harm or 24 hours even though that is not considered very expedient. IDON X indicated new orders are not always potential for actual harm seen right away by facility staff.

Residents Affected - Few On 4/17/25 at 12:04 PM, Surveyor interviewed MD V (Physician) regarding antibiotic orders and processing times for new orders. MD V indicated any order placed in the system by 5:00 PM, the pharmacy will have the new order delivered that night, any time after 5:00 PM, the pharmacy would deliver the medication the next day.

Of note, the order received on 3/6/25 was not placed into the system until 3/7/25 and R16s first dose of antibiotics was not given until 3/8/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 50285 potential for actual harm Based on observation, interview, and policy review, the facility did not ensure that each resident receives Residents Affected - Some food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect more than a minimal number of Residents (R).

2 of 2 test trays were served outside of temperature range.

Evidenced by:

The facility policy, titled Food Safety Requirements, dated 10/1/22, includes in part: .Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety . Police Explanation and Compliance Guidelines . 4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards . d. Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff shall refer to the current FDA (Food and Drug Administration) Food Code and facility policy for food temperatures as needed . 5. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include, but are not limited to: . f. Timely distribution of all meals/snacks .

Facility policy, titled Date Marking for Food Safety, undated, includes in part: . refrigerated, ready to eat, TCS (time/temperature control for safety) food shall be held at a temperature of 41 F (Fahrenheit) or less .

Example 1

On 4/3/25 at 8:45 AM, Surveyor received a breakfast test tray after all the dining room and hall trays had been served. (Of note, plates were being covered by plastic tops and bottoms, but no plate warmers were being used. The milk was poured into glasses and covered but were being kept on a tray without ice). Surveyor took the temperatures of the food that was served, including scrambled eggs, oatmeal, milk and coffee. Surveyor noted that the milk was in the temperature danger zone (temperature of 53.2 degrees F) and tasted warm.

Example 2

On 4/3/25 at 12:35 PM, Surveyor received a lunch test tray. Surveyor took the temperatures of the food that was served, including Salisbury steak, mashed potatoes and gravy, beets and milk. Surveyor noted again that the milk was in the temperature danger zone (temperature 48 degrees F) and tasted warm.

(It is important to note the milk should be held at 41 degrees F or less.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0804 On 4/3/25 at 8:54 AM, Surveyor interviewed DM D (Dietary Manager) and asked what the safe temperature was for serving hot and cold foods. DM D stated that hot foods should be served between 135 - 160 degrees Level of Harm - Minimal harm or F. DM D stated that cold foods should be served between 40 - 55 degrees F. Surveyor explained that cold potential for actual harm foods should be kept below 41 degrees F and asked if she would expect food to be served at a safe and palatable temperature. DM D stated yes, that would be her expectation. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 38882

Residents Affected - Many Based on observation. interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 41 residents who reside in the facility.

Surveyor observed food that had been removed from the original box to be undated and unlabeled.

Surveyor observed milk to be opened with no open date.

Surveyor observed magic cups to be thawed and without a thaw date.

Evidenced by:

Facility policy titled Date Marking for Food Safety, undated, includes: the food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.

The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly.

On 4/3/25 at 8:30 AM, Surveyor observed 3-gallon size white milks to be opened without an open date, mandarin oranges to have been removed from the original container without an open date or an expiration date, barbecue sauce opened with no open date, and 5 thawed magic cups with no thaw dates on them.

On 4/3/25 at 9:00 AM, DM D (Dietary Manager) indicated magic cups need to be labeled with thaw dates and all food or drink that is opened needs to be labeled with open dates. DM D indicated she was unsure when

the milk was opened, when the mandarin oranges were opened, when the barbecue was opened, and when

the magic cups were pulled from the freezer.

On 4/3/25 at 9:10 AM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) indicated food removed from the manufacturer's packaging needs to be labeled with a use by date or an opened date, opened milk needs to be labeled with an open date, and magic cups need a thaw date on them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49436 potential for actual harm Based on observation, interview, and record review, the facility did not establish and maintain an infection Residents Affected - Few prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 2 residents (Resident R2 and Resident R15) reviewed for enhanced barrier precautions.

Staff did not follow Enhanced Barrier Precautions (EBP) of wearing personal protective equipment (PPE) when providing high-contact resident care activities for Resident R2.

Staff did not follow EBP of wearing a gown when removing a wound dressing for Resident R15.

This is evidenced by:

The facility's policy titled Enhanced Barrier Precautions, dated 3/25/24, states, in part: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order for enhanced barrier precautions .will be initiated for residents with any of the following: .wounds .indwelling medical devices . High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, wound care .

Resident R2 admitted to the facility on [DATE REDACTED] with diagnoses including muscle weakness and indwelling urethral catheter (a type of catheter used for continuous drainage of urine from the bladder).

Resident R2's physician orders include Enhanced Barrier Precautions start date 7/22/24.

Resident R2's comprehensive care plan printed on 4/17/25 includes Focus: Infection actual or at risk for related to enhanced barrier precautions (foley). Interventions/Tasks: Wear appropriate PPE date initiated 7/22/24.

On 4/16/25 at 9:51 AM, Surveyor observed Resident R2 sitting in her wheelchair in her room. Resident R2's room is a double occupancy, and she does have a roommate. Resident R2 has a sign on her door indicating EBP (Enhanced Barrier Precautions) and a bin outside her door in the hallway containing PPE (Personal Protective Equipment). Resident R2's catheter bag was hanging under her wheelchair. Resident R2 had her call light on, and 2 CNAs (Certified Nursing Assistants) came to Resident R2's room to transfer Resident R2 from wheelchair to the bathroom. Resident R2 requires a sit to stand machine for transfers. CNA U pushed the sit to stand in front of Resident R2. CNA T assisted with the sling placement and moved Resident R2's catheter bag from the wheelchair to the sit to stand. CNA U raised the sit to stand and CNA T maneuvered Resident R2 to the toilet. Resident R2's pants were pulled down and brief was removed. CNA U lowered Resident R2 to

the toilet. Both CNAs washed their hands.

Of note, CNA U and CNA T did not wear gloves or a gown during this process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 45 525321 Department of Health & Human Services Printed: 08/28/2025 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 04/21/2025

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 0880 On 4/16/25 at 9:59 AM, Surveyor interviewed CNA T regarding Resident R2. Surveyor asked which resident was on EBP per the sign on the door. CNA T indicated Resident R2 is on EBP because of her catheter. CNA T then stated, Level of Harm - Minimal harm or we messed up. CNA T indicated she should have worn gloves and a gown when providing close contact potential for actual harm cares like moving the catheter and transferring Resident R2.

Residents Affected - Few On 4/16/25 at 10:00 AM, Surveyor interviewed CNA U regarding Resident R2. CNA U indicated Resident R2 is on EBP for her catheter. CNA U stated she should have worn PPE when providing cares for Resident R2 including during transfers and did not.

On 4/17/25 at 2:10 PM, Surveyor spoke with VPC S (Vice President of Clinical) regarding infection control. VPC S indicated staff should wear PPE for residents that have EBP.

50228

Example 2

Resident R15 was admitted to the facility on [DATE REDACTED] and has diagnoses that include pressure ulcer of right heel (localized injury to the skin and underlying tissue caused by prolonged pressure); chronic venous hypertension with ulcer of right lower extremity (a condition where the veins in the legs have consistently high pressure, which can lead to swelling, skin changes and leg ulcers/wounds); varicose veins of unspecified lower extremity with ulcer other part of lower leg (swollen, twisted veins that prevent blood from flowing back to the heart effectively, which can cause swelling and skin discoloration or ulcers/wounds.

Resident R15's Care Plan states, in part: Focus-Infection actual or at risk for related to: enhanced Barrier Precautions (wounds) .Interventions/Tasks .Wear appropriate PPE date initiated 7/22/24.

On 4/17/25 at 9:16 AM, Surveyor observed Resident R15's wound with IDON X (Interim DON). IDON X picked up Resident R15's right leg and removed the bandage wrap. IDON X set down Resident R15's leg, went into the bathroom, applied

a set of gloves, returned to Resident R15 and removed the border dressing to observe the wound. Surveyor asked IDON X about the cart sitting outside of Resident R15's room. IDON X stated it was there to hold a supply of PPE for residents with wounds or catheters. Surveyor asked when the PPE would be used for Resident R15. IDON X stated it would be used for any wound care. Surveyor asked if PPE is required when removing a dressing. IDON X stated yes, gloves. Surveyor asked if a gown is required. IDON X stated no, unless the resident has a positive wound culture or excessive drainage.

On 4/17/25 at 9:49 AM, Surveyor interviewed VPC S (Vice President of Clinical) and asked if any precautions are required when working with wounds. VPC S stated EBP; gowns and gloves when touching

the resident. Surveyor asked if gown and gloves are required for removal of Resident R15's wound dressing. VPC S stated yes.

On 4/17/25 at 3:20 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if staff is expected to wear a gown and gloves for removal of a wound dressing while on EBP. NHA A stated yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 45 525321